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THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

No. XLVIL— May, 1839.

COLLABORATORS.

Elisha Bartlett, M. D. Professor of
Pathological Anatomy in the Berkshire
Medical Institution,

Jacob Bigelow, M. D. Professor of Ma~
teria Medica in Harvard University,
Boston.

A. Brigham, M. D. of Hartford, Con-
necticut.

N. Chapman, M. D. Professor of the
Institutes and Practice of Physic and
Clinical Practice in the University of
Pennsylvania,

B. H. Coates, M. D. one of the Physi-
cians to the Pennsylvania Hosfpital.

Reynell Coates, M. D. of Philadel-
phia.

D. Francis Condie, M. D. of Philadel-
phia.

William P. Dewees, M. D. Late Pro-
fessor of Midwifery in the University
of Pennsylvania.

S. Henry Dickson, M. D. Professor of
the Institutes and Practice of Medicine
in the Medical College of the State of
South Carolina.

Gouverneur Emerson, M. D. of Phi-
ladelphia,

Charles Evans, M. D. Attending Phy-
sician to the Friends' Asylum, Frank-
ford,

John D. Fisher, M. D. of Boston,

E. Geddings, M. J). Professor of Patho-
logy and Medical Jurisprudence in the
Medical College of the State of South
Carolina.

William Gibson, M. D. Professor of
Surgery in the University of Pennsy l-
vania.

R. E. Griffith, M. D. Professor of
Medicine in the University of Virgi-
nia.

Thomas Harris, Surgeon U. S. Navy,
and one of the Surgeons of the Penn-
sylvania Hospital.

E. Hale, M. D. Physician to the Mas-
sachusetts General Hospital.

George Hayward, M. D. Professor of
the Principles of Surgery and Clinical
Surgery in Harvard University, Bos-
ton.

C. A. Lee, M. D. of Ne w York.

Samuel Jackson, M. D.Professorof the

Institutes of Medicine in the University
of Pennsylvania,

Samuel Jackson, M. D. late of North-
umberland, Pennsylvania, now of Phi-
ladelphia.

William E. Horner, M. D. Professor
of Anatomy in the University of Penn-
sylvania.

Valentine Mott, M. D. Professor of
Pathological and Operative Surgery in
the College of Physicians and Surgeons,
New York.

James Mac Donald, M. D. Resident
Physician to the Bloomingdale Asylum,
New York.

Reuben D. Mussey, M. D. Professor of
Surgery in the Medical College of Ohio.

T. D. Mutter, M. D. of Philadelphia.

G. W. Norris, M. D. one of the Sur-
geons to the Pennsylvania Hospital,

R. M. Patterson, M. T>. Late Professor
of Natural Philosophy in the University
of Virginia.

C. W. Pennock, M. D. one of the Phy-
sicians to the Philadelphia Hospital,
Blockley.

R, R. Porter, M. D. Late Resident
Physician to the Friends' Asylum,
Frankford,

Thomas Sewall, M. D. Professor of
Anatomy and Physiology in the Co-
lumbian College, Histrict of Columbia.

Ashbel Smith, M. D. Surgeon General
of the Tcxian Army.

Nathan R. Smith, Professor of the
Practice of Medicine in Transylvania
University.

Thomas Stewardson, M. D. one of the
Physicians to the Pennsylvania Hos-
pital.

A. F. Vache, M. D. of New York.

John Ware, M. D. Professor of the
Theory and Practice of Physic in
Harvard University, Boston.

John C. Warren, M. D. Professor of
Anatomy and Surgery in Harvard
University, Boston.

Edward Warren, M. D. of Boston,

John Watson, M. D. of New York.

Thomas H. Wright, M. D. Late Phy-
sician to the Baltimore Alms-house In-
firmary.

EDITOR — Isaac Hays, M. D., one of the Surgeons to Wills' Hospital for the
Blind and Lame, §rc.

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

VoL. XXIV.

PHILADELPHIA!

I. EA AND BLANCHARD,

SUCCESSORS TO CAREY & CO.

1839.

69427

Philadelphia :

T. K. & P. G. Collins, Printers,
No. 1 Lodge Alley.

TO READERS AND CORRESPONDENTS,

The interesting “ Gleanings” of Prof. Mott, reached us just as this sheet
was preparing for the press. They shall have a place in our next No.

We have been unable, from want of space, to notice several interesting works
to which we are desirous of calling attention; among these we may specify
Churchill on the diseases of females, Wardrop on the diseases of the heart. Dr.
Dunnel’s annual report of the interments in the city and county of New York,
for the year 1838, and Pancoast’s edition of Wistar’s Anatomy. Each of these
shall receive early attention. We have also several other works on our table,
which reached us too late for notice for the present No.

The following works have been received: —

A Treatise on the Diseases of the Chest, and on Mediate Auscultation. By
R. T. H. Laennec, M. D. Translated from the third French edition with copi-
ous notes, a sketch of the author’s life, and an extensive Bibliography of the dif-
ferent diseases. By John Forbes, M. D. F. R. S. &c. To which are added
the notes of Professor Andral, contained in the fourth and latest French edition,
translated and accompanied with Observations on Cerebral Auscultation by
John D. Fisher, M. D., Fellow of the Massachusetts Medical Society, with
plates. New York: 1838. (From Dr. Fisher.)

A system of Anatomy for the use of Students of Medicine. By Caspar Wis-
TAR, M. D., late Professor of Anatomy in the University of Pennsylvania.
With notes and additions, by Wm. Horner, M. D. Professor of Anatomy in the
University of Pennsylvania. Seventh edition, entirely remodelled and illus-
trated by numerous engravings. By J. Pancoast, M. D., Lecturer on Anatomy
and Surgery, and one of the surgeons of the Philadelphia Hospital, &c. 2

vols. 8vo: 1839. (From Dr. Pancoast.)

An Inquiry into the Influence of Physical causes upon the Moral Faculty. De-
livered before a meeting of the American Philosophical Society, February 27,
1786. By Benjamin Rush. With an introductory notice by George Combe,
Esq., of Edinburgh. Philadelphia: 1839. (From G. Combe, Esq.)

The Nature and Treatment of the Diseases of the Heart; with some views on
the Physiology of the circulation. By James W”ardrop, M. D., Surgeon to his
late Majesty, &c. London: 1837. (From the author.)

Outlines of the Principal Diseases of Females. Chiefly for the use of Stu-
dents. By Fleetwood Churchhill, M. D., Licentiate of the King and
Queen’s College of Physicians in Ireland, Physician to the Western Lying-in
Hospital, &c. &c. Dublin: 1838. (From the author.)

Practical Surgery: with one hundred and thirty engravings on wood. By
Robert Liston, surgeon. With notes and additional illustrations, by George
W. Norris, M. D., one of the surgeons to the Pennsylvania Hospital. Phila-
delphia: 1838. (From Dr. Norris.)

Outlines of the Institutes of Medicine: founded on the Philosophy of the
human economy, in health and disease. In three parts. Should we build facts
upon facts until our hill reached the heavens, they would tumble to pieces, unless
they were cemented by principles. — Rush. By Joseph A. Gallup, M. D.

Author of Sketches of Epidemic Diseases of Vermont, late Professor of Theory
and Practice in the Vermont Academy of Medicine, &c. &c. Boston: 1839. 2

vols. 8vo. (From the Author.)

Catalogue of the Officers and Students of the Medical Institute of the city of
Louisville: January, 1839. (From Professor C. W. Short.)

Introductory Lecture delivered by H. Willis Baxley, M. D., Professor of
Anatomy and Physiology in the University of Maryland. November 2, 1837,
Baltimore, 1839. (From the author.)

Annual Announcement of the Medicaf Department of Transylvania Universi-
ty; containing the circular for the present year, the catalogue of pupils of session
1838-9, and the list of graduates at the late commencement. Lexington: 1839.
(From Professor T. D. Mitchell.)

On the methods of acquiring knowledge. An introductory Lecture to the
course of the Institutes of Medicine, for the session 1838-9; delivered in the Uni-
versity of Pennsylvania, November 6, 1838. By Samuel Jackson, M. D.
Philadelphia, 1838. (From the author.)

TO READERS AND CORRESPONDENTS.

Transactions of the Medical Society of the State of New York.^ Albany:
1839. (From the society.)

A Lecture on Loxarthrus or Club Foot. By Thomas D. Mutter, M. D.,
Lecturer on Surgery, Fellow of the College of Physicians, &c. Philadelphia,
1839. (From the Author.)

Annual Report of the Interments in the city and county of New York, for
the year 1838, with accompanying remarks. Presented by Henry G. Dunnel,
City Inspector. New York, 1839. (From the author.)

Monograph of the ligneous plants indigenous to Ohio. By John L. Riddell,
M. D., Professor of Chemistry and Pharmacy in the Medical College of Lou-
isiana. (From the author.)

Opinion of the Court of Appeals of Maryland, in the case of the Jlniversity
of Maryland, delivered by Buchanan, Chief Justice. Baltimore, 1839.

The Annual Address to the candidates for degrees and licenses in the Medi-
cal Institution of Yale College, February 26th, 1839. By Thomas Miner,
M. D., Member of the Board of Examination, and late President of the Con-
necticut Medical Society. Published at the request of the Class. New Haven,
1839. (From the author.)

An Address delivered to the Students of the Louisville Medical Institute in
the presence of the citizens of the place, at the commencement of the second
session of the Institute, November 13th, 1838. By Joshua B. Flint, M. D.,
Professor of Surgery, Louisville, 1838. (From the Author.)

Archives Generales de Medecine, September, October, November and De-
cember, 1838. (In exchange.)

Revue Medicale Fran(;aise et etrangere, August, September, October, No-
vember, December, 1838. (In exchange.)

Journal de Medecine et de Chirurgie Pratiques, September, October, Novem-
ber, December, 1838. (In exchange.)

Bulletin General Therapeutique Medicale et Chirurgicale, September, Octo-
ber, November and December, 1838. (In exchange.)

Gazette Medicale de Paris, August, September, October, November and De-
cember, 1838. (In exchange.)

Journal des Connaissances Medico-Chirurgicales, September, October, No-
vember and December, 1838. (In exchange.)

Journal des Connaissances Medicales, September, October, November and
December, 1838. (In exchange.)

La Lancette Franqaise, August, September, October, November and Decem-
ber, 1838. (In exchange.)

Journal de Pharmacie, September, October, November aud December, 1838.
(In exchange.)

Zeitschrift fiir die gesammte Medicin mit besonderer Riicksicht auf Hospital-
praxis und auSlandische Literatur. Nov. 1838. (In exchange.)

The London Medical Gazette, November and December, 1838, and January,
1839. (In exchange.)

The British and Foreign Medical Review or Quarterly Journal of Practical
Medicine and Surgery, Januai‘y, 1839. (In exchange.)

Edinburgh Medical and Surgical Journal for January, 1839. (In exchange.)

The Medico-Chirurgical Review, for January, 1839. (In exchange.)

The Medical Examiner for February, March and April, 1839. (In exchange.)

The American Medical Library and Intelligencer, for February, March and
April, 1839. (In exchange.)

The Boston Medical and Surgical Journal for February, March and April,
1839. (In exchange.)

The Southern Medical and Surgical Journal, February, March and April,
1839. (In exchange.)

The Select Medical Library and Eclectic Journal of Medicine, February,
March and April, 1839. (In exchange.)

The Transylvania Journal of Medicine and the Associate Sciences, for April,
May and June, 1838. (In exchange.)

The Western Journal of the Medical and Physical Sciences for May, June
and July, 1838. (In exchange.)

CONTENTS.

ORIGINAL COMMUNICATIONS.

MEMOIRS AND CASES.

ART. page

I. Account of the Asylum for the Relief of persons deprived of the use of

their Reason, near Frankford, Pennsylvania, with the Statistics of the
Institution from its foundation to the 31st 12th month, 1838. By Charles
Evans, M. D., Attending Physician to the Asylum. - - - 13

II. Observations on the Nature and Treatment of Telangiectasis, or that

morbid state of the Blood-vessels which gives rise to Naevus and Aneu-
rism from Anastomosis. By John Watson, M. D. (Read before the
New York Medical and Surgical Society, March 2d, 1839.) - - 24

III. Chronic Cerebral Affection: long continued, intense headache: double
consciousness: extraordinary memory of events: inefficacy of treatment:
diagnosis doubtful. By Elisha Bartlett, M. D., Professor of the Theory
and Practice of Physic, and Pathological Anatomy in Dartmouth College. 42

IV. Case of Cancerous Ulceration of the (Esophagus opening into the

Trachea. By Morrill Wyman, M. D., Cambridge, Mass. - - 58

V. On the Remedial Powers of the Persesquinitrate of Iron. By T. C.

Adam, M. D., of Lenawee county, Michigan. - - - - 61

VI. Remarkable Case of Partial Sweating. By Samuel S. Marcy, M. D.,

of Cold Spring, N. J. - - - - - - - 66

VII. Case of Epilepsy. By Charles A. Porter, M. D., of New York. - 67

VIII. Bite of a Spider on the Gians Penis, followed by violent symptoms —
recovery. By Isaac Hulse, M.D., U. S. N. Fleet Surgeon, W. I. Squa-
dron. ---------69

IX. A Brief Account of Scarlatina, as it prevailed in the Orphan House,
Charleston, South Carolina, during the months of June and July, 1838.

By George Logan, M. D., Physician to the Institution. - - 71

MONOGRAPH.

X. On Pseudomembranous Inflammation of the Throat. By E. Geddings,

M. D., Professor of Pathological Anatomy and Medical Jurisprudence in
the University of the State of South Carolina.

Synonymes — Pseudo-membranous inflammation of the throat. Angina
Pseudo-membranacea. Angina tonsillaris membranacea. Angina Plas-
tica. Angina Diphtheritica, (Bretonneau.) Angine Couenneuse, (Guer-
sent.) Hautige Braune. Germ. - - - - - 73

CONTENTS,

ART. PAGE

Bibliography. - -- -- -- - 89

BIOGRAPHY.

XI. A Memoir on the Life and Character of Philip Syng Physick, M. D.

By J. Randolph, M. D. - - - - - - - 93

REVIEWS.

XII. Lectures on the Morbid Anatomy of the Serous and Mucous Mem-

branes. In two volumes. Vol. i. By Thomas Hodgkin, M. D., Lon-
don: 1836. 129

XIII. First Principles of Medicine. By Archibald Billing, M. D., &c. &c.
Third Edition, considerably Enlarged and Improved. 8vo, pp. 282.
London; 1838. -------- 145

BIBLIOGRAPHICAL NOTICES.

XIV. The kiinstliche Pupillenbildung in der Sclerotica; Nebst einem an-
hange iiber die Verpflanzung der hornhaut, Keratoplastik. Nach eigenen
Versuchen. Von Dr, B. Stilling, Gehulfarsarzt am Landkrankenhause
zu Marburg. Marburg, 1833, 8vo. pp. 144.

On the Formation of an Artificial Pupil in the Sclerotica, with an Appen-
dix on the Transplanting of the Cornea. By Dr. B. Stilling, &c. - 163

XV. Appreciation de la Doctrine Phrenologique ou des localisations des
Facultes Intellectuelles et morales, au Moyen de I’Anatomie Comparee.

Par M. .Jules Lafargue, ancien interne des hopitaux.

An appreciation of the Phrenological doctrine, or the localisation of the
intellectual and moral faculties, by means of comparative anatomy. By
M. J. Lafargue. - - - - - - - -168

XVI. Die Gefassdurchschlingung. Eine neiie methode, Blutungen aus
grdsseren Gefassen zu Stillen. Von Dr. B. Stilling, prakt arzt zu Cas-
sel. 8vo. pp. 152, Marburg, 1835.

Die natiirlichen Processe bei der Heilung durchschlungener Blutgefasse
mit besonderer Riicksicht auf den Thrombus. Aus einer grossen reihe
Von Versuchen an Thieren abgeleitet. Von Dr. B. Stilling, &c. 8vo.
pp. 304, Eisenach, 1834.

Geschichte einer amputation des oberschenkels, wobei die* durchschlin-
gung der art. fern., art. prof. fern, und der vena fern, in anwendung gezo-
gen wurde. Von Dr. B. Stilling, &c. 8vo. pp. 32, Hanover, 1837. - 172

XVII. Recherches Medico-physiologiques sur L’Electricite Animale: Sui-

vies d’observations et de considerations pratiques sur le precede medical
de la neutralisation electrique directe, notamment appliquee au traite-
ment de I’Ophthalmie, de I’Erysipele de la Face, de la Cephalalgie, de
la Migraine, des Derangemens de la menstruation, des Affections rhuma-
tismales, de quelques Affections nevropathiques, &c. Par J. F. Cou-
dret, M. D. P. &c., Paris, 1837. pp. 496. pi. III. - - - 176

XVIII. A Treatise on the Diseases of the Chest, and on Mediate Auscul-
tation. By R. T. H. Laennec, M. D., Regius Professor of Medicine in
the College of France, &c. &c. &c., translated from the third French
edition, with copious notes, a sketch of the author’s life, and an exten-
sive Bibliography of the different diseases. By John Forbes, M.D.F. R.

S. &c. &c. To which are added the notes of Professor Andral, contain-
ed in the fourth and latest French edition, translated and accompanied

CONTENTS.

PAGE

with observations on cerebral Auscultation, By John D. Fisher, M. D.
Fellow of the Massachusetts Medical Society. With plates. New
York, Samuel S. & Wm. Wood, 1838, pp. 784, PI. II. - - - 178

XIX. — A Lecture on Loxarthus or Club-foot. By Thomas D. Mutter,

M. D., Lecturer on Surgery; Fellow of the College of Physicians, &c.
Philadelphia, 1839. pp. 104. 8vo.- ----- 178

XX. Practical Surgery; with one hundred and thirty Engravings on Wood.

By Robert Liston, Surgeon. With notes and additional illustrations, by
George W. Norris, M. D., one of the Surgeons to the Pennsylvania Hos-
pital. Philadelphia, James Crissy, 1838, pp. 374, 8vo. - - 179

XXL Tenth Annual Report of the Inspectors of the Eastern Penitentiary
of Pennsylvania. Philadelphia, 1839, pp. 28, 8vo. - - - 179

XXII. An Introductory Lecture to a Course of Lectures on the Theory
and Practice of Medicine, in the University of Pennsylvania: Delivered
at the opening of the Session of 1838-39. By N. Chapman, M. D.

Prof. &c., Philad. 1838, pp. 19. 8vo. ----- 184

SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.

General Anatomy and Physiology.

PAGE

1. Case of Natural Somnambu-
lism. By Dr. Verdet - - 185

2. Observations on the Fluid of
the Vesiculae Seminales of Man.

By Dr. John Davy. - - 187

3. On the Veins of the Uterine
Decidua. By Dr. Robert Lee. 188

Pathological Anatomy

6. Exostosis of the Pelvis of

unusually rapid growth. By
Wm. Lawrence, Esq. - - 191

7. Hepatic Abscess opening into
the Stomach by three perfora-

Materia Medica and

9. Kermes Mineral as an emetic
and purgative. By Dr. Toul-
mouche. - - - - 195

page

4. On the Venous Circle of the

Mammary Areola. By Profes-
sor Sebastian. - - - 19(>

5. On the accessory Supra-Renal
Capsules. By Professor Sebas-
tian. ----- 190

AND General Pathology.

tions; also into the Pericardium.

By R. J. Graves, M. D. - - 192

8. Silver Spoon swallowed — after-
wards discharged through an
abscess in the epigastrium. - 195

General Therapeutics.

10. Method of determining the
genuineness of Ergot. By Mr.

T. H. Wardleworth. - - 196

CONTENTS.

PAGE

11. Medical Properties of Zinc.

By G. G. SiGMOND, M. D. - 196

12. On the Properties and Thera-
peutic powers of Camphor. By

G. G. Sigmond, M. D. - - 198

Special Pathology and

14. Treatment of Irritation of the

Stomach. By Jonathan Os-
borne, M. D. - - - - 201

15. Neuralgia of the Testicle. By

Dr. Graves. - 204

16. Method of preparing Sina-
pisms for the purpose of with-
drawing Gout from the vital
organs to the extremities. - 204

17. l^eatment of Permanent Hy-

pertrophy of the Tonsils. By
Dr. Graves. - - - - 205

18. Spasm of the Glottis or La-
ryngeal Asthma. By Dr. T.

H. Burgess. - 205

19. Efficacy of Emetics in remov-
ing Paralysis of the Facial
Nerve. By Dr. C. J. Heidler. 211

PAGE

13. Value of Creosote as compar-
ed with other remedies. By
Dr. Da Luz. - - - - 201

Special Therapeutics.

20. Hepatic Abscess. By Dr.

Jackson. - - - - 212

21. Case illustrating the History,
Symptoms, Pathology and mode
of Treatment of Simple Ulcera-
tion of the Stomach. By Lang-
ston Parker, M. R. C. S. - 214

22. On Simple Ulceration of the

Stomach, with observations on
those forms of gastric irritation
which more commonly precede
and. accompany it. By Lang-
ston Parker, Esq, - - - 215

23. Experiments on the applica-
tion of narcotics in the form of
Vapour. By C. W. Hufeland. 221

24. Heart diseases not seated in

the heart. By C. W. Hufeland. 222

Surgery.

25. Encysted Dropsy of the Thy-
roid Gland. By Dr. Selwyn. - 224

26. Division of the Prostate in

Lithotomy. By H. M. Phil-
lips, Esq. - 224

27. Fearn’s case of Aneurism of

the Innominate, treated by liga-
ture of the Carotid and Sub-cla-
vian arteries. - - - - 225

28. On the cure of wryneck by
dividing the sterno-cleido-mas-
toid muscle beneath the skin.

By Prof. Dieffenbach. - - 226

29. Hydrocele. By M. Dujat. - 231

30. Dislocation of the Radius for-
wards. By Mr. Coley. - - 232

31. Extirpation of the Tongue.

By M. Regnoli. - . - 232

32. Case of Ileus in which Gas-
trotomy was performed. By

M. Monod. - 233

33. Desault’s apparatus for frac-
tured femur. - - - - 235

34. Hydrocele treated by acu-
puncture. By Dr. Davidson. - 235

35. Dislocation of the Humerus,

attended with a grating sensa-
tion on motion, leading to the
supposition that the case was
complicated with fracture. By
Wm. Lawrence, Esq. . - 236

36. Malignant Ulcer under the
left ear cured by chloride of
zinc. By Wm. Davidson, M. D. 237

37. Treatment and Causes of Ery-

sipelas. By Wm. Davidson,
M.D. - - - - -238

Ophthalmalogy.

38. Glaucoma. By Dr. Wm. Mac-
kenzie. - - - - - 240

39. Use of the essential oil of

Turpentine in diseases of the
Eye. By Dr. A. Trinchinetti. 242

40. Hereditary Hemeralopia. By
M. Florent Cunier. - - - 242

CONTENTS.

Midwifery.

PAGE

41 . On the Position of the Placen-
ta in the Womb during pregnan-
cy, and on the manner in which
the latter organ expands therein,
as also of its subsequent contrac-

PAGE

tions in the process of Parturi-
tion. By Hugh Carmichael,

Esq. - - - - - 242

42. Unconscious Delivery. By
Robert Hall, Esq. - - - 243

Medical Jurisprudence and Toxicology.

43. Poisoning with Arsenous acid I 44. Effect of Respiring Carbonic

successfully treated by the Hy- j Acid. By C. T. Coathupe. - 244

drated peroxide of iron. By
Dr. Deville. - - - - 243

Medical Statistics.

45. Vital Statistics of Glasgow.

By Dr. Robert Cowan. - - 246

46. Periodical Mortality of the

Human Race. - . - 250

47. Greater number of still-born

in illegitimate than in legiti-
mate births. By Prof. Jorg. - 251

48. Pauper Lunatics and Idiots
in England and Wales. - - 251

Animal Chemistry.

49. Urea in the Blood in Chole- 150. Analysis of the Liquor Amnii.
ra. By Dr. Rainy. - - 251 | By Dr. G. O. Rees. - - 252

Miscellaneous. '

51. Revaccination. By M. De- | New Books, - | - 252

zeimeris. . - - - 252 j

AMERICAN INTELLIGENCE.

On the Catoptric examination
of the Eye. By the Editor. - 255
Expulsion of one twin Foetus,
the other retained to the full
period. By S. Jackson, M. D. 256
Closure and obliteration of the
Os uteri, during pregnancy. By
Samuel Weber, M. D. - - 256

Case of Club-foot treated by
division of the Tendo Achillis.

By Thomas J. Garden, M. D. - 257

New Vaccine Virus. - - - 258

Report of Thomas Lawson, M.D.
Surgeon General of the United
States Army. - - - - 258

Malignant Pustule. - - - 259

Osteo-sarcoma, and excision
of a large portion of the lower
jaw. By Dr. J. Wort. - - 260

Wound of the Stomach. - - 261

Dr. S. & G. H. White’s Lunatic
Asylum at Hudson, N.. York. 262

CONTENTS.

PAOE

Massachusetts General Hos-
pital. - - - - 262

Philadelphia Medical Society. - 264
University of Pennsylvania. - 264
Transylvania University. - - 263

University of Maryland - - 264

, V-

PAGE

j Dartmouth College. - 264

I Medical College of Georgia. - 264

(Geneva College. - - - 264

Louisville Medical Institute - 264
I New Works. - 264

ERRATA.

It is stated in the review of Professor Jackson’s Report on Typhoid fever, in
our No. for November last, p. 132, that there is^vidently some mistake in the cal-
culations. The writer of the article was led into this error from a misapprehen-
sion of the manner in which the tables of the author were drawn out. These
tables are made to show how frequently each symptom considered separately,
presented itself; but, as in some of the cases, two or more symptoms occurred
together, without it being stated how often this happened, one who was not
aware of this fact, might readily suppose the number of cases to have beeu
greater than it really was, and thus infer an error in the calculations.

We may notice at this time a typographical error at p. 134, next line to bot-
tom, in which none is placed for one. It should read, in one there was perfora-
tion of the intestine.

These corrections should have been made in our preceding No., and we owe
many apologies to our estimable and respected correspondent for the omission.

/r'.V. Z///.

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

Art. I. Account of the Asylum for the Relief of persons deprived of the
use of their Reason^ near Frankford^ Pennsy Ivania, with the Statistics
of the Institution from its foundation to the 3lst I2th month, 1838.
By Charles Evans, M. D., Attending Physician to the Asylum.

Of all the maladies to which the human system is obnoxious, those which
affect the manifestations of mind have undoubtedly the strongest claim upon
our sympathy and care. Notwithstanding this is now generally acknow-
ledged, yet it is comparatively of but recent time, that the public sympathy
has been effectively demonstrated, by providing adequate and appropriate
means for the cure of persons afflicted with those diseases; or for alleviating
the distress and securing the comfort of such as may be beyond the reach
of remedial aid. All experience has proved, that in the great majority of
cases, separation from friends, and seclusion from society, are indispensable
to the recovery of the insane; besides which the peace of their families,
and the well being of society, demand their restraint; hence, places for their
reception have been common in all Christian countries: but until the. pre-
sent century, these institutions appear to have been conducted, mainly, with
a view to the security of their wretched inmates; provision for their medical
and moral treatment, being altogether unheeded, or made of very secondary
consideration. Left to the conduct of the ignorant, the selfish, and the
unfeeling, whose principal aim was to escape trouble and secure their own
emolument, the mad-houses (as the English termed them,) embraced more
heart-sickening degradation, and more unheeded suffering, than could be
found in any other receptacles of human misery. The real state of the
No. XLVIl.— May, 1839. 2

14 Evans’s Account of the Frmikford Asylum.

houses for the reception and treatment of the insane, in Great Britain was
first disclosed to the public by the report of a committee of the House of
Commons, published in 1816. Credulity itself is staggered at the recital,
of the before unheard of cruelty practised, and misery endured, within the
walls of most of those institutions, many of which, the public had been
accustomed to regard with pride, as monuments of their liberality and bene-
volence. There were, however, a few honourable exceptions, and conspi-
cuous among these was the Retreat near York, which was projected by
the Society of Friends as early as 1792, the same year in which Pinel com-
menced his celebrated reform in the Bicetre at Paris. The plan of that
Institution originated with a few individuals in the society, who, having acci-
dentally become acquainted with the manner in which the insane were
habitually treated, resolved to rescue such of their fellow professors as suf-
fered under that pre-eminent affliction, from the misery which surrounded
them, and to place them in a situation where they would be subjected to a
totally different course of management from that pursued in any of the
existing establishments. Accordingly grounds were purchased, buildings
erected, and in 1796 a considerable number of patients received, and a
course of treatment carried out, such as had never before been practised
towards the insane, and which gave a rational ground to hope that their cure
would be effected, or, at all events, their comfort and welfare secured. The
Retreat was soon resorted to by others than Friends, and in a short time the
success obtained there, demonstrated beyond contradiction, the superior effi-
cacy, both in respect of cure and security, of a mild and humane system of
treatment in all cases of mental disorder. To the philanthropic members of
that religious society, who founded and conducted the Retreat, belongs (toge-.
ther wdth Pinel, who made some reformation in the horrible abuses of one
of the Paris hospitals,) the credit, whatever it may be, of changing the
course of treatment long pursued toward those deprived of the use of their
reason, and restoring to them that sympathetic kindness and control which
their affliction jpeculiarly demands. The example thus set was slow in ex-
tending its iniuence, as is evident from the state of the institutions through-
out Great Britain, when the investigation before alluded to, took place. That
it had, how'cver, a decided effect in awakening the public mind to the im-
portance of a reformation in the insane hospitals, is shown by several parts
of the evidence given before the committee of the House of Commons.
Dr. Weir, Inspector of Naval Hospitals, states in his testimony, that “the
object of almost every insane institution, whether of a public or private
description, had been the security of those pitiable objects; comfort, medi-
cal and moral treatment being in great measure overlooked; happily, how-
ever, for that class of society, the Quakers’ Retreat at York, has at last
convinced the world, how much may be done towards the amelioration of
their condition.”

From the time the subject was thus brought before the public, the

Evans’s Account of the Frankford Asylum. 15

arrangement and economy of asylums for the insane have become the sub-
jects of attentive study and experiment, until, under the influence of an
enlightened philanthropy, they have been radically changed, so that within
the w^alls of every such institution properly conducted, are congregated, not
only the various resources of medical science and art, and every thing calcu-
lated to divert the mind from its erroneous associations, and give new vigour
to its powers; but also, all that needful care, decided control, and well-di-
rected kindness, which, owing to perverted feelings, the sufferer rejects, or
cannot appreciate while within his own domestic circle, but which are gene-
rally accepted with thankfulness from the hands of a stranger, and contri-
bute powerfully to lessen his distress and restore his health.

In 1812, motives, similar to those which actuated the founders of the
Retreat in England, induced a large number of the members of the same
society in Pennsylvania, to attempt the establishment of a similar institu-
tion. They associated themselves together under the title of “ The Con-
tributors to the Asylum for the Relief of Persons deprived of the use of
their Reason,” for the purpose (as expressed in their constitution,) of pro-
viding for the suitable accommodation of that afflicted class of our (their)
fellow members, and professors with us, (them) w'ho are or maybe deprived
of the use of their reason; as well as the relief of their families and friends.”
Subscriptions were opened, and in the course of a comparatively short time,
a sufficient amount of funds having been collected, the institution which I
am about to describe was built, and in 1817 opened for the reception of
patients. At that time there was no asylum in this country which could
serve as a model for an institution of the kind, those existing only answer-
ing to show how entirely inappropriate for the accommodation of the insane
were the plans upon which they were constructed.

The Asylum for the Relief of Persons deprived of the use of their Rea-
son, is situated in a healthy and retired part of Oxford township, distant
about five miles north from Philadelphia, and one mile westward from
Frankford. The whole building, which faces the north, is three hundred
and twenty-two feet eight inches in length, being made up as follows:

The centre building is sixty feet square and three stories high above the
basement; having two wings standing back about eighteen feet from its
front, each one hundred feet long by twenty-four feet in depth, and two
stories high; terminating in end buildings, which project four feet in ad-
vance of each wing, and are thirty-one feet four inches in front, by twenty-
eight feet four inches in depth, and three stories high, exclusive of the base-
ment. From each of these end buildings, a wing, running south, at right
angles with the front, extends twenty-six feet eight inches in length, by
twenty-two feet six inches in depth, and corresponding in height with the
front wings.

The first story of the centre building contains four large rooms, divided
from each other by halls running at right angles, one of which leads directly

16 Evans’s Account of the Franhford Asylum,

through the building from north to south, and has the staircase in it, while
the other opens into each wing. The two front rooms are appropriated,
the one as a parlour for the superintendant, the other as an office and re-
ceiving room; the two in the rear, which respectively communicate with the
wing of the side on which it is situated, are used as day-rooms for the
patients. The second story of this building also contains two large rooms,
situated with respect to the wings like the two below, and like them appro-
priated as day-rooms for the patients, besides which, there are four smaller
rooms used by the family of the superintendant. There are four large, and
three smaller rooms in the third story. One of the larger is occupied by
the resident physician, and one as a sitting room for the convalescent female
patients; the apothecary shop is also on this story. The wings each con-
tain twenty good-sized rooms for patients, with a lobby or passage ten feet
wide, running the whole length in front of them, at the extremity of which
is the staircase. The end buildings, or lodges, as they are called, though
united to the wings by the front wall, yet have their other walls entirely dis-
tinct; and in the lower story, are separated from the wings by a passage five
feet wide, leading to the airing yards. Immediately over this passage, is
the staircase leading from the second to the third story of the lodge. The
rooms, both in the body of the lodges and their wings, are on the west
side, with an entry six feet wide running in the rear of them on the east
side; these entries are lighted by a window at each end, the wall on the side
next the wings being unbroken and of extraordinary thickness. This sepa-
ration of the two lodges from the rest of the building, is for the purpose of
preventing the transmission of sound, and is found effectually to prevent the
convalescent and quiet patients, who are kept in the wings, from being in-
jured or annoyed by the noise of the violent and unruly ones, who are con-
fined to the lodges. The first story of the lodges contains the bath rooms,
a day room and two rooms for patients; the other rooms in the different
stories, for the accommodation of the patients and their care-takers, are
about twelve feet square.

In the centre building are the refectory, kitchen, ironing-room, and store-
room; rooms for cooking, washing, <fcc., are adjoining under the wings,
where also are the furnaces; furnaces are likewise located in the basement
of the lodges. The whole building is covered with slate, and may be
said to be nearly fire-proof. The basement story is paved with brick or
flags, and arched, while the bottoms of the floors, and the joists in all parts
of the house are thickly plastered with mortar, and then ceiled in the usual
manner. In all parts of the building accessible to the patients, the window
sash is of cast iron, and stationary. The lower one in each window is
glazed, and outside of the upper is a wooden sash, glazed, which is hung,
so as to be raised or lowered at pleasure. This arrangement, while it en-
sures security from escape, prevents the appearance of a place of confine-
ment. The rooms in the centre building, and the patients’ day rooms, ex-

Evans’s Account of the Frankford Asylum, 17

cept those in the lodges, are warmed by means of stoves and grates. The
wings and lodges have heated air, conducted from the furnaces before men-
tioned, as located in the basement story, into the lobbies and each room.
The openings for the admission of the warm air into the rooms, are near
the ceiling, and covered with wire-gauze, and the air can be stopped off at
any time by means of dampers, situated so as to be regulated only by the
attendants. Some of the rooms are provided with shutters for the exclusion
of light when required, as also with wire protection to the glass.

Immediately under the roof in each wing is a large reservoir for water,
supplied by means of a forcing-pump, from a never-failing stream, which
issues forth a short distance from the house. From these reservoirs the
water is conveyed to the bath rooms, and various other parts of the
building.

The great extension of front in a building intended for the accommoda-
tion of but sixty-five patients, was deemed necessary in order to give to
each, a separate, well proportioned room, having all the advantages to be
derived from the free admission of light and air. Where the rooms are
arranged on both sides of an entry of the usual width, these two essential
requisites to health and cheerfulness cannot be commanded; added to which,
the patients occupying opposite rooms are very liable to be mutually annoy-
ing, and in every respect (unless it be that of saving money), that mode of
building for the insane is highly objectionable. On this account the plan
adopted at the Friends’ Asylum is worthy of imitation.

On one side of the wings are situated the chambers, ten feet square, each
having a window, four feet six inches in height, by two feet ten inches in
width. These rooms open on to the lobby, ten feet wide (as before mention-
ed), and directly opposite the door of each room is a window corresponding
in size with that in the room. Over each door is fixed a cast iron sash,
thirty-two by twenty inches in size, fitted with a moveable glazed sash, to
be opened or shut at pleasure. Ey this arrangement, a full supply of light
and a free circulation of air are secured, and the lobbies being comfortably
warmed in cold weather, they afford pleasant places for walking and exer-
cise of different kinds.

The kitchen and refectory, situated on the back part of the basement
story of the centre building, open on to an area, which is fifteen feet wide
opposite the centre building, and connects with one ten feet wide running
the whole length of the western, and past that of the eastern wing. These
areas are paved with brick, and have a well, fitted with a pump in them.
The outside of the area is sodded, and rises regularly to a level with the
garden and yards in the rear.

A neat vestibule, having its sides enclosed with Venetian shutters, sixteen
feet in length, and corresponding in width with the large hall running
through the ground floor of the centre building, is thrown over the widest
part of the area, and leads directly into a flower-garden. In the rear of the

18 Evans’s Account of the Frankford Asylum,

wings and lodges are the airing yards, each surrounded by walls ten feet in
height, enclosing about half an acre of ground, for the use of such of each sex,
as are not well enough to be allowed to walk, unattended, in the gardens
and pleasure grounds. Each yard is subdivided by a board fence, cutting
off about one-third of it; into which the idiotic and filthy patients are put,
that they may not offend those who take more care of themselves. These
yards are made pleasant with trees and summer-houses, the passages leading
to them, as before mentioned, are between the wings and end-buildings.
The entrances to the privies are from these yards: a door opening through
the wall into them; there are no water-closets or other accommodation of
the kind, within the buildings. Between these yards is a large flower-
garden, and immediately beyond them the vegetable garden; the two con-
taining about two acres of ground. At the termination of a gravel walk
leading directly from the house through these two gardens, at the distance
of about three hundred feet, is an ornamental house, surrounded on all sides
by a piazza, fitted up as a library and reading room, and containing nume-
rous specimens of natural history, maps, drawings, &c. &c., affording a
most agreeable resort for such patients as may be considered by the physi-
cian well enough to enjoy it.

Over the spot where rises the stream that supplies the institution with
water, at a short distance from the eastern end of the building, is erected a
stone house, two stories in height, beside a basement; the lower story of
which contains a forcing-pump so arranged, as to be easily worked by four
of the patients; while the upper one is fitted up as a work-shop, with a
turning lathe, tools, &c. Here many of the patients find interesting em-
ployment.

Connected with the various buildings described, is a farm of sixty-one
acres, the greater part of which is under cultivation, and by giving the pa-
tients the opportunity for various agreeable and active out-door employ-
ments, affords the most powerful means for their restoration to health and
reason. The woodlands cover about eighteen acres of ground, and are
made up principally of the chestnut, beach and oak, affording a deep and
delightful solitude and shade. Abroad serpentine walk, more than a mile
in length, winds throughout them, and a large summer-house and seats in
various situations, are provided for the accommodation of the patients.
Near the entrance to the woods, and enclosing a small part of them, is a
park containing some fine deer.

Experience having proved that the comfort and cure of the insane are
materially affected by the construction of the building in which they are
placed, numerous plans have been suggested and acted upon, each of
which has its admirers. All however who have had any practical know-
ledge of the treatment of those labouring under the disease, and their liability
to be acted upon by the objects which surround them, unite in the senti-
ment, that that plan will prove the^ best, which, with equal conveniences,

Evans’s Account of the Frankford Asylum, 19 >

combines the most means for introducing well-adapted employment and ex-
ercise, with the best arrangement for an extensive classification which can
be kept permanently distinct.

Where the conveniences for classification are wanting, the most lamenta-
ble consequences must necessarily be witnessed even in institutions which
may otherwise be conducted in the most unexceptionable manner. The
employment of moral remedial means, is either absolutely precluded or ren-.
dered nugatory, when the patient upon the first dawn of reason feels the
horror of being constantly surrounded by his pitiable associates, in all the
different gradations of maniacal phrenzy and idiotic imbecility. These
evils are guarded against at the Asylum by such a classification as is allow-
ed of by the arrangement of the building.

The male patients occupy the eastern, and the female the western side of
the house, both sides being arranged alike. The end buildings, or lodges,
are occupied (as before mentioned), exclusively by the noisy and imbecile.
Such of them as are fit to be out of their own rooms, have the liberty of a
well-lighted and cheerful day room, situated in the southern extremity of
the lower story of the wing of the lodge. Another class of patients oc-
cupy the lower story of the main wing, and have for their sitting roonfi the
large room described as forming part of the lower story of the centre build-
ing. The upper story of the wing is devoted to a third class who are more
nearly well, and such as show no violence, and conduct themselves gene-
rally with propriety; they likewise have a day room for their peculiar
accommodation, situated on the second story of the centre building, corres-
ponding with the one below. All these patients, however, have access to
the same yard, excepting that the worst are confined to a small part of the
yard, which is boarded off, as before described.

For the accommodation of such of the females as are nearly restored,
there is a large room in the third story of the centre building fitted up as a
drawing room, where they can pursue their various amusements and em-
ployments entirely undisturbed by the other inmates of the house. There
is no such room for the men, but the same class of patients among them,
usually resort to the library, when circumstances will not admit, or they are
not disposed to walk abroad. Such of the patients as do not eat in their own
rooms, take their meals in the day rooms attached to the respective parts
of the building where they are placed.

The government of the institution is lodged in the hands of a steward
and matron, and resident physician, whose whole time is devoted to fulfil-
ling the various duties of their respective stations. An attending physician
visits the patients regularly twice a week, and as much oftener as the urgen-
cy of a case may require. A Board of twenty Managers, appointed yearly
by the Association, have the supervision of the whole, and by a
committee of three, inspect every part of the establishment once in each
week.^

20 Evans’s Account of the Frankford Asylum*

In the treatment pursued at the Asylum, endeavours are used, so to com-
bine medical and moral agents, that each shall render the other its most
efficient aid, and jointly exert their remedial powers with the greatest cer-
tainty and effect. The therapeutical treatment of course varies accord-
ing to the disease, which by affecting the brain, disturbs the manifestations
of the mind. An accurate account of such treatment and its results, is con-
stantly kept, and at some future day may afford data for ascertaining the
relative advantages of the course pursued.

The moral means employed are various. Where it is found necessary,
mild and gentle yet firm restraint is imposed, while the earliest gleams of
returning reason are watched and cherished.

In the house, there are provided, games of different kinds; reading,
writing, drawing, &c. The females sew, knit, quilt, The library is

furnished with ^ooks, periodicals, drawings, &c. Exercise in the open air
is always promoted, and the patients encouraged, whenever the weather
will permit, to engage in walking and riding. A carriage and horses are
always in readiness, morning and evening, for their accommodation. In the
lawn fronting the house, is located a circular rail-road about four hundred
and fifty feet in circumference, with a pleasure-car on it, large enough to
accommodate two, which is moved by hand. Riding upon this road is a
very favourite amusement, and as it is attended with considerable exercise,
it is found highly advantageous. Every exertion is made to interest the
male patients in gardening, and in the various employments afforded in the
cultivation of the farm. The diet of the patient of course varies according
to the prescription of the physician, but in general it is plain and nutritious;
fresh meat and a variety of vegetables being served up every day. Tea,
coffee, and milk are all abundantly supplied.

The Asylum was opened for the admission of patients in the 5ih month
of 1817, and the following table exhibits the number, sex, and social state
of those received yearly, up to the conclusion of 1838.

Year.

Whole

number,

Men.

Women.
1 Single.

1 Married.

Widowers )

Year.

Whole

number.

1 c
! «

Women. |

[ Single.

1 Married.

Widows.

1 Widowers.

1817

9 13

1828

1 S

1818

8 9

182.9

1819

7 10

1830

1820

10 14

1831

1821

9 15

1832

1822

14 13

1833

1823

8 10

1834

1824

810

1835

1825

15 12

1836

1826

1112

1837

1827

11 10

1838

Evans’s Account of the Frankford Asylum. 21

Whole number of admissions,

- ■'

“

((

Men,

331

((

Women, -

•

303

Single, -

326

Married, -

234

Widowers,

Widowsj

Of these there

were below 20

years of

age.

From

20 to 30 years,

. - '

187

30 to 40

■ -

141

40 to 50

126

50 to 60

60 to 70

70 to 80

80 to 90

90 to 100

- 634

Of these 634 admissions, 127 were re-admissions granted to 81 individuals,
and leaving 507 persons who have been under care.

The following table shows the duration of the disease at the time of ad-
mission of these 507 cases, and the results of treatment.

Duration.

Number,

Restored.

Much Imp.

Improved .

Stationary

Remaining

Died.

•

Less than 1 year,

261

152

From 1 to 2 years,

From 2 to 3 years,

From 3 to 5 years.

From 5 to 10 years.

Over 10 years,

Aggregate,

507

214

The proportion of cures in these cases is 42.21 in every hundred; but if
we deduct the sixty-one cases, which at the time of admission had been
deranged over ten years (and which included twenty who either were idiots,
or had been imbecile from puberty), five cases complicated with epilepsy,
and five which entered the institution with the paralysis peculiar to the
insane, it leaves 436 cases, properly subject to treatment, and the cures are
in the proportion of 49 in every hundred.

The per centage of cures in cases of less than a year’s duration, taking

22 Evans’s Account of the Frankford Asylum,

the whole twenty-two years is 58.23. Within the last six years, it has been
66. Nearly all of this class, discharged as “ much improved,” were almost
well; but either pecuniary considerations, or the anxiety of their friends, oc-
casioned their removal as soon as the disease was so overcome as to
render their perfect restoration probable; and in many instances information
was afterwards received of their perfect recovery.

Of the seventy deaths, six occurred within a week of the time of their
admission; nine within two weeks; seven within three weeks; and three
within four weeks; these were mostly cases of acute inflammation of the
brain, or its meninges, many of them being brought to the Asylum after
all hope of relieving them at home was abandoned. Ten died between a
month and a year’s residence, and the remainder varying from one year to
twenty.

Of the eighty-one patients re-admitted, there were discharged

Restored, - -- -- --36

Much Improved, 4

Improved, - -- -- -- 6

Stationary, ------- 7

Died, - 17

Remaining in the House, - - - - 11

Twenty-two returned a third time; of whom there were discharged — Re«
stored, 14. Improved, 3. Stationary, 3. Died, 3 — and one remains in
the house. The other re-admissions, were of three individuals, who being
liable to periodical insanity, have been accustomed to resort to the Asylum
at the commencement of an attack, and to remain there until again restored to
the use of their reason.

The following table exhibits the ages of the persons re-admitted, and the
duration of the attack at the time of their first admission.

Age.

No.

Duration of Disease.

No.

Below 20 years,

Less than 1 year,

From 20 — 30

From 1 to 2 years,

From 30—40

From 2 to 3 years.

From 40 — 50

From 3 to 5 years,

From 50 — 60

From 5 to 10 years,

From 60 — 70

Above 10 years.

From 70—80

From 80 — 90

Forty-one of the eighty-one had been originally discharged cured. The
interval between the discharge and re-admission, was as follows.

Evans’s Account of the Frankford Asylum.

Less than three months,

of whom 8 had been discharged cured.

Between three and six months,

of whom 2

do.

six months and 1

year.

do.

1 and 2 years,

do.

2 and 3 years,

do.

3 and 5 years.

do.

5 and 10 years,

do.

Over

10 years.

do.

In some of the cases where this interval was so short as to be within
three months, the second indisposition should no doubt be considered as a
relapse; the organs not having been restored to perfect soundness after the
original attack. But when we recollect how prone an organ which has
once been diseased, and especially the brain, is, to resume the morbid action
upon the occurrence of even a trivial cause, and also that that organ is liable
to be affected not only by the causes which produce disease in other parts
of the system, but likewise by the moral feelings and emotions of the mind;
it is not to be wondered at, that a recurrence of disease should often be
witnessed where persons are taken from the seclusion and regular habits
of an Asylum, and ushered into the cares and excitement of society, as
soon as healthy action is believed to have been restored. It is a difficult
matter to convince a patient, or his friends, that prudence dictates his slay
should be prolonged for a considerable time after he is apparently well, yet
it cannot be doubted, that where such a course is pursued, the security of
health is greatly increased.

As has been before observed, the Asylum was originally intended for the
accommodation of those in membership or profession with the Society of
Friends alone; and it continued thus exclusive, until the year 1834, when
the contributors withdrew the restriction, and opened the institution for the
benefit of all, with the proviso, that “in no case should a member or pro-
fessor be excluded.”

An accurate record of the place of nativity of each patient, and whether
member or not, has been kept from the opening of the institution. By this
it appears that the average number of the members of the General Meeting
of Friends held annually in Philadelphia, which were under care (including
idiots) during the first ten years in which the Asylum was opened, was
thirty-one. That meeting includes the greater part of Pennsylvania, New
Jersey and Delaware, and during those ten years was composed of between
twenty and twenty-three thousand members; which, taking the medium,
twenty-one thousand five hundred, which I believe is nearly correct, gives
the proportion of one in every six hundred ninety-three and a half. In
1827, a large body seceded from that meeting, and its numbers are not now
so accurately known; the ratio, however, has not increased.

Dr. Burroughs in his Commentaries, gives currency to the opinion that
insanity occurs in a greater proportion among the members of the Society

Evans’s Account of the Franhford Asylum.

of Friends, than the population generally, and assigns as a reason, their
intermarriage with each other. This however would be entirely insufficient
to account for the greater prevalence of the disease among them, if such
were really the case, as in Great Britain, from whence he draws his data,
there are nearly if not quite twen,ty-five thousand members; a number so
large as to do away the probability of its being attributable to hereditary
taint.

As the records of the two institutions for the insane, belonging to the So-
ciety, show that intemperance and want, so productive of mental derange-
ment among others, cannot be assigned as the causes of it, in, more than one
case in every hundred and fifty occurring in the members of that society,
and as they are known to be exempted, at least equally with others, from
the sources of anxiety which disturb the social state; there would appear to
be no other causes for the disproportion of diseases affecting the manifesta-
tions of mind, did it really exist, than either defective cerebral organization,
or some peculiarity in their religious principles or practices. The former, no
one will believe to be the case, and religious mania, as it is commonly but
improperly called, is a form of the disorder which so rarely occurs among
them, that as a community they may be said to be almost exempt from it.

The true reason of the apparent disparity in the proportional number of
those afflicted with derangement in that society, and the community at large,
lies in the very defective statistical information obtained of the latter rela-
tive to a disease which the ignorance and prejudices of the people lead them
to conceal, and upon which incorrect data, a false estimate has heretofore
been made. While in the Society of Friends, an accurate knowledge of all
the members, liberal provision for the support of their poor, and institutions
for its cure under their own care and government, bring nearly every case
of idiocy or insanity which occurs among them, under notice.

Art. II. Observations on the Nature and Treatment of Telangiectasis, or
that morbid state of the Blood-vessels which gives rise to Nsevus and
Aneurism f tom Anastomosis. By John Watson, M.D. Read before
the New York Medical and Surgical Society, March 2d, 1839.

By Telangiectasis, as the etymology of the word implies, is meant a
dilated state of the extreme vessels. The term was first employed by
Graefe, it has since been used by other writers of Germany, France, Eng-
land and America; and as applied to a morbid condition of the blood-vessels,
it is synonymous with the nsevus maternus of the older writers, the aneu-
rism from anastomosis of John Bell, the tumeur variqueuse or fongueuse
sanguine of Boyer, the tumeur erectile of Dupuytren. I have adopted it

Watson’s Observations on Telangiectasis. 25

as more applicable to the cases about to be related, than either of these other
terms; it covers the whole ground occupied by a natural group of maladies;
it alludes to the actual state of the blood-vessels without referring to the
cause, real or imaginary, that gives rise to this; it involves no theory as to
whether these diseases be seated in the veins, the arteries, or both; it im-
plies not that these diseases should in all cases exist at birth; and includes
those that are deep-seated, as well as such as are visible or superficial.

Previous to the time of John Bell, the superficial forms of telangiectasis
were denominated naevi materni or mothers’ marks; and the French in allu-
sion to a prevalent notion that these marks are caused by longings and men-
tal impressions of the mother during gestation, have commonly termed them
envies. But the deeper forms, or such as lie beneath the skin without
involving it, before the time of Bell, had no specific name assigned to them;
they were either described as anomalies, or confounded with a variety of
other affections. Without attempting to enter at present upon the pathology
of the tumours which Bell has described under the head of aneurism from
anastomosis, it may here be well to remark that this name is defective and
improper; first, in implying that the disease is seated solely in the arteries;
and secondly, that the anastomoses of these vessels are more abundant than
natural.

Mr. Wardrop has attempted to show that the vascular nmvus is a disease
entirely different from the aneurism by anastomosis, and finds fault with
other writers for confounding them: yet none of the distinctive signs
which he has specified, can be taken in any other light than as pointing to
mere varieties of a disease common to both veins and arteries, frequently
confined to the capillaries, but often extending to the other vessels.

Many of the French writers, and some even of our own country who
have treated on this disease, have confounded it with that variety of carci-
noma which Hey has described under the name of fungus hematodes.
Some too, after having discovered this error, have committed another in
retaining the name fungus hematodes in their account of the severer forms
of the disease now under consideration. Even Dupuytren, who takes to
himself the credit of having first illustrated the pathology of what he calls
erectile tumours, has aided in perpetuating this confusion: for, under the
head of his erectile tissue he includes aneurism from anastomosis as de-
scribed by Bell, fungus hematodes as described by Hey and others, and
a great variety of normal structures, both in men and other animals, which
serve as the type of these two morbid growths. Bell indeed had previously
pointed out the analogy in structure between the aneurism from anasto-
mosis, and the normal tissues which Dupuytren has included with it; so
that this latter writer has added nothing to our pathological knowledge by
his labours on this subject.

The cases of telangiectasis requiring treatment that have fallen under my
own observation, have been neither suflSciently numerous nor sufficiently
No. XLVII — May, 1839. 3

W atson’s Observations on Telangiectasis.

diversified to illustrate this point of pathology in all its bearings; I shall be
obliged therefore in the course of my remarks to refer, for some of the
severer forms of this disease, to the cases of other "writers.

Case I. — In March, 1837, I saw with Dr. Stevens an infant ten months
old, the daughter of Mr. K,, who had for some months past been under
treatment for a pulsating tumour on the right side of the face. The tumour
was still increasing, and when first seen by Dr. Stevens (March 23d) it
extended from just below the inner canthus of the eye, downwards and
outwards on the cheek, presenting a circular elevation an inch and a quarter
in diameter, lying mostly beneath the integuments, but raising the skin about
three-fourths of an inch above its natural level.

The spot from which the present deformity originated, according to the
mother’s account, was not observed until some days after the child’s birth,
and when first noticed, it was a mere point of bright red colour under the
inner corner of the right eye. When the child was three months old, the
swelling was as broad as the mother’s thumb nail, somewhat elevated, and
throbbing. At this period the parents became alarmed, and consulted Dr.
Mott, who applied caustic potassa to the tumour. This produced an eschar
which separating, left an ulcerated surface W’hich continued open about
eight weeks, and during this time hemorrhage occurred occasionally, but
never to any alarming extent. The ulcer finally cicatrized without chang-
ing the character of the tumour. It still continued to grow, and in Novem-
ber, 1836, its diameter at the base was about an inch.

The parents at this time applied to Dr. Bushe, and he pierced the tumour
with three cautery needles heated to whiteness. This operation caused some
hemorrhage at the time, and was followed by considerable inflammation,
but not of sufficient severity to change the character of the tumour, or to
arrest its growth. The operation was repeated in February, 1837. No
hemorrhage followed the second application of the needles, the subsequent
inflammation was slight, and the final result of this cauterization was as
unsuccessful as the first.

From a drawing taken at Dr. Stevens’s first visit, (I did not see it until
after he had operated upon it,) the disease appears to have originally involved
the skin, and to have afterwards extended to the subjacent tissues. It is re-
presented of a light pink colour, interspersed with minute scarlet points, and
with larger spots of a purplish hue.

Having learnt the nature of the previous operations, and dreading the de-
formity, not to speak of the danger, likely to result from any attempt at extir-
pating the tumour. Dr. Stevens, with the view of exciting inflammation
sufficient to change the character of the vitiated growth, determined upon
introducing a seton. A blunt-pointed needle, armed with several silk threads,
was accordingly passed from the inner towards the outer edge, and com-
pletely under the swelling; the needle was withdrawn, and the silk threads
left as a seton in the wound. No hemorrhage followed the operation;, the
threads were sufficiently numerous to fill the track of the needle, and thus
to prevent bleeding.

On the fifth day after the operation, suppuration was established along the
course of the seton; the inflammation gradually extended to the tumour, and
continued to increase until April 15th, (twenty-three days after the insertion
of the threads,) at which time the external character of the swelling was
suddenly changed, and purulent matter was evidently forming within it. On
the following day the existence of pus was still more manifest; the bright

Watson’s Observations on Telangiectasis,

red colour of the integuments had given place to a pale yellowish tinge; and
the whole tumour had the appearance of a large phlegmon about to burst.
.The circumference, however was still red; and on the edge next the eye the
original character of the swelling was still perceptible.

^pril llth. An eschar formed in the centre, and the abscess broke, giving
issue to a copious flow of dark brown consistent pus. This continued to
ooze out in considerable quantity for several days afterwards.

April ‘IMh. The seton was withdrawn from beneath the tumour. The
inflammation excited by it had, since the bursting of the abscess, already
much abated; and the tumour was reduced to one-third of its former size.
A purplish spot, however, still existed at the upper edge, indicating that the
portion of the tumour at this point was still unaltered; but, with this excep-
tion, the whole of the diseased tissue had become indurated.

June Sth. The swelling was still further diminished; the purplish spot
still observable; the abscess not yet entirely healed; and the appearance of
the integuments about it, such as are usually presented in the normal tissue
under chronic inflammation.

After this date I lost sight of the case until December, 1838. On examin-
ing the child, at this period, not the slightest vestige of the disease remained;
the integuments were of their natural colour, and the cicatrix was only ob-
servable on minute examination.

In accordance with the distinctions attempted by Mr. Wardrop, between
naevus and aneurism from anastomosis, this tumour would belong to the
latter class. It differed from his subcutaneous naevus, first, in having ori-
ginally manifested itself at some time after birth; secondly, by originating in
the skin, and extending afterwards to the subjacent tissues; and, lastly, in
having a pulsatory movement. In short, the morbid development appears
here to have been seated in the capillary arteries, whilst in the disease de-
scribed by Wardrop, the corresponding veins were the vessels most affected.*
It is worthy of further observation, in this case, that the caustic potassa, and
even the cautery needles, appear to have excited so trifling a degree of in-
flammation; and even when this w'as effectually established by the seton, its
progress was unusually slow, several months having intervened between the
formation of the abscess and its final closure. This same observation, I find,
has also been made by Mr. Lawrence, who states that, in one portion of
these morbid structures, inflammation may progress to mortification, without
exciting inflammation in other parts immediately adjacent.f But, when once
inflamed, these tissues are apt to sphacelate, as may be seen by consulting
the cases of Pelletan and others; and perhaps in the ca-e just related, the
abscess might have for a long time been prevented from closing, by a portion
of this mortified tissue remaining at the bottom of it.

Case II. — Mr. H.’s son, three months old, was seen. Sept. 18th, 1837,
having three n^vi on its back, and another on its arm, near the elbow. The
largest of these was about two inches in diameter, and seated behind the left

* See his remarks in the Lancet, vol. xii. p. 394, (June 30, 1827,) and his earlier paper
on this subject in the Medico-Cliirurgieal Transactions, vol. ix. p. 199.

t Lancet, vol. ix. p, 163.

28 Watson’s Observations on Telangiectasis.

shoulder, involving the skin in its central part; but extending beneath the
skin without involving it in the circumference. It was also somewhat ele-
vated, and had an ulcerated spot in the middle, as large as a ten cent piece.
It had existed at birth, and had grown considerably since; and, when pressed,
it communicated to the finger an obscure thrill, or pulsating movement. The
second was about one-fourth as large as this, and was seated on the opposite
shoulder. The third one was very small, and lay immediately below the
preceding. These two, as well as the spot on the elbow, were not observed
at birth; they had not grown so rapidly as the first; they were apparently
confined to the skin itself, and were somewhat elevated. Their colour was
a bright purple; but the subcutaneous portion of the first one had a different
hue, as if caused by the purplish colour striking through the healthy skin.

Through the largest of them Dr. Stevens introduced a seton, passing it,
as in the preceding case, beneath the apparent base of the naevus. The
second spot was removed by excision, the knife extending to the sound in-
tegument, a line or more beyond the boundaries of the naevus. Very little
blood followed the operation: the integuments were drawn together over the
wound by a suture and adhesive straps. The third spot was not molested
at this time; but in a few days afterwards it was touched with cali purum.
The spot on the elbow was left entirely to itself.

In a few days after these operations, the seton had ulcerated its way
through the centre of the principal spot, without producing much irritation
or inflammation. Another seton was introduced in an opposite direction,
add the surface of the spot was brushed over with cali. The wound left by
the incision had not united by the adhesive process, and was left to granu-
late. An eschar had formed over the third one, to which caustic had already
been applied.

On the 30th of September, the part upon which the incision had been
made was nearly cicatrized; the spot beneath it was granulating, but not so
far advanced in cure. The large naevus was now an open fungous ulcer, and
at first sight it might easily have been mistaken for a fungus hematodes.
The second seton had nearly ulcerated its way through. Caustic was again
freely applied over the surface of the sore, and a compress and roller em-
ployed, in order to repress the fungous growth.

Subsequent to this date, the two small spots on the back required no fur-
ther treatment. The last application of caustic had the effect of destroying
the fungus; the ulcerated surface gradually closed, and at the end of three
months the disease was completely eradicated. But the integuments over
the principal spot preserved a bluish tinge for some time afterwards. The
spot upon the elbow still persists, without any disposition to grow larger.

The spots in this case appear to have been confined to the capillary ves-
sels, and to have originated in the skin. The rapidity with which the setons
ulcerated their way through the large naevus, does not prove that the vitality
of the tumour was very great; but, on the contrary, that it was less than
natural; and the slight degree of inflammation produced by the threads, is
confirmatory of this remark. Judging from this case, the seton does not
appear to be well adapted for the cure of superficial nsevi, especially where
the base is broad; — the caustic, in this case, was evidently much more
effectual.

Case III. — Mr. S.’s daughter, six months old, had a congenital naevus on

Watson’s Observations on Telangiectasis. 29

the right side, near the lower margin of the thorax: it was altogether cuta-
neous, of a bright red colour, and somewhat elevated; it did not pulsate, and
was about an inch and a half in diameter. When first observed, it was not
elevated above the surface, and was not larger than a five cent piece; but
within the last few weeks, it has been rapidly increasing.

On theL2d of November, 1838, Dr. Stevens, embracing the diseased por-
tion of integument with a pair of forceps, elevated it, and removed it by one
stroke of the bistoury. A small artery was observed in the centre of the
wound thus made; which, from its brisk hemorrhage, appeared to be much
larger than the cutaneous vessels usually are. The blood poured from it in
jets, and a ligature was required to arrest tlie hemorrhage. On examining
the extirpated portion of skin, the continuation of this vessel was observed
entering at the centre of the diseased spot; and, even in its contracted state,
its calibre was sufficiently large to admit a thick bristle.

The edges of the wound were approximated by adhesive straps, and in a
few days afterwards the child was entirely w&ll.

The organization of the naevus in this case, was apparently the same as
in the preceding cases; and that the capillary arteries were the principal seat
of disease, is proved by the dilated state of the cutaneous artery, through
which the rnorbid structure was supplied with blood. Was the naevus in
this case owing to the dilated condition of the vessel leading to it? or was
the ililaiation the necessary result of the increased flow of blood towards the
diseased tissue? By consulting other cases, in which the expansion of the
vessels was much more marked than in this, we find that the increased de-
velopment of the larger vessels always begins at or near their capillary ter-
minations, and gradually progresses on towards the heart; that the dilatation
is often, but not always, attended with thinning of the coats of the vessels, but
without ulceration, or any other sign of inflammatory action, in the great
majority of cases. The vessels too are not merely dilated; they are also
much increased in length, and twisted on themselves, and convoluted in a
great variety of ways.

Case IV. — Mrs. Geer’s son, aged five months, was brought to me on the
19lh of June, 1838, with a naevus on the breast just over the centre of the
sternum. It manifested itself soon after birth, and has since gradually in-
creased. When I first saw the tumour it was about three quarters of an
inch in diameter, and was elevated at least half that extent above the level
of the skin; it was of a bright red colour, appeared to be extending to the
sub-cutaneous tissues, and had a thrilling movement.

I passed a curved needle armed with silk threads from above downwards
through the base of it; and lying these threads tightly on either side of
the swelling, I attempted to strangulate it.

June22d. The ligature on the right side had produced partial ulcera-
tion and sloughing at the base of the naevus. On the opposite side the
string had become loose; and slipping upwards on the side of the naevus,
had forced the blood out of its spongy tissue without completely strangu-
lating the part. The ligature was again tightened.

June 2Sth. The ligatures ulcerating their way through the diseased skin;
but at a point somewhat above the outer edge of the naevus, so that a small
rim of the morbid tissue is likely to be left.

30 Watson’s Observations on Telangiectasis.

After this date, I lost sight of the case until the month of December fol-
lowing. I now found the central portion of the naevus replaced by healthy
skin; but around this there was still remaining a ring of the diseased tissue.
This ring was not elevated, it gave out no pulsation, its colour was bright
red, its diameter was about half an inch, and its rim was not more than a
line in breadth.

February 18//i, 1839. The spot has extended to the sub-cutaneous
tissue, and is again becoming elevated. When pressed with the finger it
gives a doughy feel. Its colour in the centre is that of the healthy
skin; but in the circumference it is much darker than formerly, and the
sub-cutaneous veins extending from it towards the top of the sternum, are
fuller and more distended than natural; so much so as to be remarked by
the mother herself. She is much concerned lest the spot “ should begin
to grow more rapidly and bleed, as the vines begin to grow in the spring.”

From this case we see the propriety, when it is possible, of removing the
whole of the morbid tissue; and we have in it another evidence of the
difficulty with which inflammation is brought about in theso structures.
Had the outer rim of the naevus been sufficiently inflamed by the liga-
tures, and subsequent ulceration in the centre, the diseased portion would
have been altered, and made to assume its normal character as in the
first case related. The disease in this case is now clearly connected with
the veins.

Case V. — Miss M. W. when a child, had a nasvus on the right side of
her forehead. It appeared soon after birth, at first of a faint pinkish hue,
which gradually increased to a bright red; it continued to increase for about
two years, at which time it was nearly as broad as a quarter of a dollar; it
was elevated above the surface, but flattened on the top; and so far as I
can recollect, it gave a thrilling motion to the finger. Its degree of turges-
cence, and its colour varied with the state of the circulation. It remain-
ed stationary for a year or so longer, and then began gradually to be effaced.
At the end of eight or nine years, the skin had assumed its healthy appear-
ance in colour and structure, and there is now no remaining evidence on
the forehead that a naevus had ever existed there.

From this case we learn that these tumours may occasionally disappear
spontaneously without ulceration; a fact contrary to the opinion of some
writers, and one by no means common: for, though they often become
eflfaced, yet it is exceedingly rare for them to disappear and leave the skin of
its natural colour.

Case VI. — Mr. C., a Scotchman, about 45 years old, in consulting with
me for another disease in July, 1838, requested me incidentally to examine
his back. I discovered a flattened sub-cutaneous tumour, somewhat irregu-
lar on its surface and in its shape; and, to speak within bounds, covering
about a square foot along the right lumbar region, and so on up the back
and round towards the right side. Towards the centre of the tumour the
integuments were involved for about two inches square, and were of a deep
purplish colour verging to black. Over the remainder of the swelling, the
skin was of its natural colour and texture. The tumour was very yielding
and inelastic, like soft spunge, and had no unnatural pulsation. The dis-
coloration in the centre of the swelling had existed since birth: but was

Watson’s Observations on Telangiectasis, 31

originally very small. During his youth it extended to the sub-cutaneous
tissue, and for a time grew rapidly; but for the last twenty years or more,
it has remained stationary. At times it becomes turgid and distended, and
then again subsides into its present state. It gives him no inconvenience
except when it becomes turgid, and then it is attended with burning and
stinging pains.

Nothing but post-mortem inspection could render it more clear, that the
tumour in this case was owing to a dilated condition of the capillary veins.
The colour, the inelastic spongy feel, the entire absence of pulsation; all
show that the minute arteries formed no prominent part of it. In this re-
spect it corresponds with the sub-cutaneous n^vus of Wardrop; but it
differs from that in having spread originally from the skin to the subjacent
cellular tissue.

Case VII. — In the summer of 1828, a young woman from the country
came to town to undergo an operation for a round and prominent swelling
of a purplish-black colour, about the size of a wild cherry, on the margin
of the lower lip near the left commissure. It had existed there since her
inhmcy. It was removed by two incisions, one on each side of it, running
obliquely downwards so as to meet each other beneath its base. The wound
in the lip was afierw^ards drawn together by a stitch and adhesive straps. In
a few days the parts had become adherent, and the deformity caused by the
removal of the V-like flap, was scarcely observable.

This, like the preceding ease, is one in which the venous capillaries
were chiefly involved; scarcely any portion of the tumour however extended
beneath the integuments.

Case VIII. — The facts of the following case have been generously fur-
nished me by my friend Dr. Alexander Hosack of this city.

Dr. Hosack, about six years since, had charge of an infant four months
old, with a congenital naevus on the side of its head. The tumour appeared
to be situated wholly beneath the skin. The integuments over it were in-
flamed, and the tumour was rapidly increasing. It did not appear to pul-
sate on pressure; it was much elevated, spongy, and easily emptied of its
blood; but after removing the pressure it rapidly filled again with a sort of
pulsatory action. At the time of attempting its removal, it was about the
size of a dollar. It was removed by excision. Brisk hemorrhage followed
the operation; before the surgeon or his assistants had time to arrest the
bleeding, the infant had swooned, and in ten minutes afterwards it expired.

The nasvus in this case was connected with enlargement of the temporal
artery, which beat very forcibly; and Dr. H. is of opinion that the tumour
was formed by the immediate ramifications of this vessel. A case similar
to the preceding is related by Mr. Wardrop. The tumour was sub-cutane-
ous and situated on the back of the neck. “It was of the form and size of
half an ordinary orange,” and was rapidly increasing. On the tenth day
after its birth, the skin gave way and a profuse hemorrhage followed without
reducing the size of the tumour, which felt warmer than the surrounding
parts, and was compressible to one-third its ordinary size. “ Conceiving
the immediate extirpation of this tumour the only chance of saving the

32 * Watson’s Observations on Telangiectasis,

infant,” says he, “ I removed it as expeditiously as possible, and made the
incision of the integuments beyond the boundary of the tumour; aware of
the danger of hemorrhage where such tumours are cut into. So profuse
however, was the bleeding, that though the whole mass was easily removed
by a few incisions, the child expired.”"*^

Case IX. — An infant about three months old was brought to the New
York Hospital to be treated for a swelling on the right side of the neck be-
hind the slerno-mastoid muscle, and just above the clavicle; it was of a
flattened ovoid shape, about two inches long, and not quite so broad; it was
entirely subcutaneous, and quite moveable; it was easily compressed, had a
doughy feel, and was free from all pulsation. The integuments over it were
healthy, but had a tinge somewhat darker than natural from the colour of
the tumour beneath. The swelling was gradually increasing.

I saw this case but once, and know nothing of the result. It is the only
case I have observed to correspond in all respects with the subcutaneous
naevus of Wardrop.

Case X. — An infant was brought to the New York Dispensary with a
small cutaneous naevus on its forehead. The child had not been vaccinated,
and the vaccine physician proposed to apply the virus over the naevus, stating
that he had cured several similar spots in this way — the virus was accord-
ingly inserted, the eruption that followed was smaller than usual, and after
its desiccation the naevus still persisted.

Case XI. — -Ann Scarlet, aetat. 23, admitted into the Cheltenham Hospital,
November 17th, 1828, with a congenital naevus extending in detached por-
tions on the outer side of the limb from the upper part of the thigh to the
extremity of the little toe. When she was about seven years old, the veins
of the leg first began to enlarge. At ten or thereabouts, a vein under the
naevus on the outer side of the knee, gave way; she thus lost sufficient
blood to produce fainting; the bleeding was finally arrested by pressure.
From this time the limb enlarged rapidly, and every autumn scabs formed
on different parts of the naevus which ulcerated and bled considerably. In
June, 1827, she was married. During her pregnancy the limb increased
more rapidly than formerly; and in the centre of the large portion of the
naevus, after considerable inflammation, an abscess formed and discharged
a teacupful of pus mixed with blood. She aborted at the end of the fourth
month, and subsequent to this the limb had somewhat diminished.

At the date of her admission, she was pale from the frequent loss of blood,
and her form was slender and much emaciated. A considerable portion of
the naevus on the thigh was in a state of ulceration, and bled at every
change of dressing; a similar bleeding ulcer existed near the ankle. The
veins of the leg on the outer side of the limb, says Mr. Averill, were in a
more varicose state than any he had ever seen; while those on the inner side
of the limb were entirely unaffected. The diseased thigh was an inch and
a half more in circumference than the other; and the calf of the diseased
leg was five inches and a half greater than that of the sound limb. She
suffered great pain in the limb, had occasional discharges of blood from the
hemorrhoidal veins; and sometimes, when sick, threw up blood from the
stomach.

* Medico-Chirurg. Transact. Vol. ix. p. 202.

Watson’s Observations on Telangiectasis. 33

The disorder of the stomach was relieved by the internal use of nitrate
of silver, aided by a blister over the epigastrium. Bandages were tried for
unloading the veins of the limb, but these were found to bo painful and of no
avail, and were consequently abandoned. An elastic stocking and thigh-
piece, contrived for the occasion, answered a better purpose; the thigh-
piece however was not applied until after the ulcer had healed. She con-
tinued the use of the apparatus until leaving the hospital, (January 23d,
1829) being restricted, in the mean time, to light and easily digested food.
Her general health was now restored; her thigh was reduced to its natural
size, and the leg very little larger than the other. The veins were also
much diminished in size. She was directed to continue the use of the
apparatus.

This is one of the most striking cases I find on record of general dilata-
tion of the larger veins of a limb connected with a nsevus. A case, no
doubt of the same kind in which the vessels of the arm and hand were in-
volved to a very great extent, is related by Mr. Abernethy. Mr. Adams has
reported some cases in which naevi, situated on the tongue, were connected
with great enlargement of the veins. This form, he says, “ grows slowly
and has no pulsation. At other times it assumes a sudden increase of size,
particularly in females during the menstrual period.”* But as a still more
positive proof that the veins are ajt times extensively involved, we may refer
to a preparation of this sort in Guy’s Hospital Museum, presented by Sir
Astley Cooper.f

Case XII. — Catharine Micart had two congenital spots of the colour of
wine lees, one upon the left ear, and the other on the left parietal region. In
the course of a few years the two spots united, and produced considerable
tumefaction. About her eleventh year, the tumour began to increase, small
openings occurred spontaneously upon it, and gave issue to arterial hemor-
rhage. A free incision was made into it, from which a great quantity of
blood escaped; but this was permanently arrested by pressure, and in a month
afterwards the wound had cicatrized. In the mean time the tumour con-
tinued to increase. In September, 1805, the patient, then eighteen years
old, entered the Hotel Dieu, in consequence of bleeding produced by a puncture
which had been made some days previous at the upper part of the ear.

The tumour at this time occupied the whole of the temporal region, and
appeared to be composed of arteries enormously dilated. The ear was red,
large, and agitated throughout by pulsations synchronous with those of the
heart. At the top of the helix was a cicatrix which gave way at the slight-
est touch, and the crevice resulting from its rupture furnished a brisk and
obstinate hemorrhage; and this was renewed at every attempt to change the
dressings. Pressure applied over the temporal artery arrested the move-
ment and pulsation in the anterior part of the tumour. Permanent com-
pression over this vessel was therefore commenced as a means of cure; but

* Dublin Journal, (from the report of the Transactions of the British Association for
1835,) Vol. viii. p. 218.

f Catalogue of the Anatomical Museum of Guy’s Hospital. London, 1829, preparation
1538, marked “Nsevus Maternus of Foot; it consists of a congeries of dilated veins,
which are filled with wax.

Watson’s Observations on Telangiectasis,

it was found to be too painful to be continued. M. Pelletan next undertook
to secure the temporal and occipital arteries: but in the operation the tem-
poral artery was transfixed, and only partially taken up; and in passing the
needle under the occipital artery, blood gushed out from both extremities of
the puncture; but after dividing the integuments over it, this vessel was se-
cured, and pulsation ceased in the tumour. Compression was again em-
ployed, but it produced a slough, in consequence of which it became neces-
sary to dress the part oftener than usual; at each dressing the hemorrhage
recurred; and the pulsation, though less strong than formerly, was renew-
ed. In the course of treatment, constitutional symptoms ensued, erysipelas
appeared on the face, an abscess formed in the centre of the tumour, and
another over the sternum; the occipital artery bled frequently; and finally, at
the end of two weeks from the operation, the patient sunk.

In the post-mortem examination, the integuments of the scalp, and of the
left ear, were found of their natural structure. There was a cicatrix at
the parietal protuberance: behind this, the opening of an abscess; and upon
the helix, a small opening filled with clotted blood. Under the skin, from
the zygoma and occipital tuberosity up to the top of the head, existed a
thick layer of dense cellular tissue infiltrated, or rather interspersed, with
small and distinct masses of pus. The cellular tissue of the ear was very
red, and was formed by the interlacing of a great number of dilated veins
and arteries.

All the arteries comprised in the tumour below this tissue, were dilated,
tortuous, and nodulated in a very irregular manner; and filled either with
coagulated blood, or with a white thick humour. The temporal artery was
dilated and pervious to within an inch of the ligature; that portion of the
vessel which had not been included in the ligature formed a fibrous cord at
the bottom of the wound. The vessel higher up, and its branches, were en-
larged, as before stated; and the branches of the occipital artery were also
knotted, tortuous, and dilated.

The arteries throughout the body, according to Dupuytren’s testimony,
were thinner than natural, and the smaller ones collapsed like veins, from
which they were with difficulty distinguished. This wasting of the parietes
of the arteries was much more remarkable in the vessels of the fifth or sixth
order, than in those of larger size. Purulent depositions were found in the
liver; and there were evidences of recent inflammation of the pleura, the lungs
being united to the parietes of the chest.

This case has been differently related by Pelletan,* * * § who had charge of it,
and by Dupuytren, who furnished an account of it for Breschet’s Essay on
Aneurism, j* It is also related by BoyerJ and other French writers, and ap-
pears to have been the first case that called the attention of the French sur-
geons to this subject. § The patient’s death may be attributed, not to the

* Clinique Chirurgicale, tome ii. p. 59.

t Me moires de I’Academie Roy ale de Medecine, tome iii. p. 154.

t Maladies Chirurgicales, ii, p. 374.

§ Pelletan, CKnique Chirurg. tome ii. p. 65. Other cases of this disease, recorded as
anomalies, are to be found in the works of several of the older continental writers. One
of the most striking and graphic of these is quoted by Boyer, tome ii. p. 378, from the
Mem. de I’Acad. des Sciences de Montpellier, tome i. He also refers to cases of the same
disease in the writings of Fabricius Hildanus, Severinus, and J. L. Petit.

Watson’s Observations on Telangiectasis. 35

irritation of the tumour; but rather to the inflammation of the vessels, and
the secondary abscess following the operation. It is evidently a case in
which the naevus extended from the capillaries, its original seat, to the larger
arteries; but that there must have been also some congenital weakness pre-
disposing to this disorder in the arteries, is probable, from facts observed by
Dupuytren. Breschet relates a case similar to this, on the right side of the
head, in a woman over sixty years of age, who died of exhaustion from fre-
quent hemorrhage. The structure of the tumour was similar to the prece-
ding: “ The right carotid w^as much dilated, tortuous, and three times its
natural length. An' analogous disposition was observed in the whole course
of the aorta; but not to so marked a degree: the same condition was observed
in the primitive iliacs, but the vessels of the extremities were natural. In
every part where the arteries were dilated and twisted, their parietes were
thin, soft, flaccid, and more like the parietes of veins than of healthy
arteries.”*

Breschet also relates another case of this disease, in which both veins and
arteries were enormously dilated. The tumour originated in the left thyroid
gland. The patient was a boy about ten years old; and in the course of a
year the swelling had grown to be as large as a child’s head at birth. An
attempt was made to extirpate it; but the violent hemorrhage during the
operation deterred the surgeon from proceeding: a metallic ligature was
drawn round the base of the tumour, the bleeding was thus arrested; but
the child became convulsed, and died in the course of the night. “ The
thyroid veins, but more especially the arteries, both the upper and lower on
the left side, were tortuous, and essentially composed the tumour by their
numerous branches, the calibre of which was developed to ten times their
natural size.”f

The few cases of Telangiectasis now related are sufficient for illustrating
its pathology; and when considered in connection with other cases of similar
character, recorded by J. Bell, Abernethy, Pelletier, Boyer, Travers, Dal-
rymple, Wardrop, Law’rence, Marshall Hall, Macilwain, Roux, Breschet,
Dupuytren, Bushe, and others,:}; we have a collection of facts sufficient for
establishing its various forms, as well as its identity, under the variety of
names and arbitrary distinctions that have hitherto been assigned to it.

How much soever then the morbid structures denominated naevi materni,
aneurisms from anastomosis, pulsating vascular tumours, varicose tumours,
bloody tumours, erectile tumours, angiectasis, telangiectasis, &c. may differ

* Memoires de I’Academie Royale de Medecine, tome iii. p- 177.

t Ibid. p. 133.

X Rayer, Maladies de la Peau, tome ii. p. 664, refers to an ^extensive paper on this
subject by Claudius Tarral, in the Archives Generales de Medecine for 1834. This I
have not as yet been able to obtain.

36 Watson’s Observations on Telangiectasis.

from one another in their symptoms and progress, they all essentially depend
upon a preternatural and irregular development of the minute blood-vessels;
the disease in most cases, if not in all, occurring primarily in the capillaries,
from which, in progressing, it may extend to vessels of much greater size.

That the capillaries are the vessels primarily affected, is sufficiently esta-
blished by the fact that when the disease is effectually arrested in its early
stages, either by excision or otherwise, the morbid growth is invariably pre-
vented from extending to the larger trunks; and that in those cases where
the vascular development never progresses to the formation of a tumour,
but produces merely a discoloration without any elevation on the surface of
the skin, no other vessels than the capillaries are involved. I do not find an
instance to show that the dilatation ever progresses from the larger to the
smaller vessels; but, on the contrary, the disease, commencing in the capil-
laries, may extend to all the vessels of a limb, or even to the largest vessels
of the body.

This mode of progression is of some importance in showing that the dila-
tation of the capillaries is an active state, and not the result of passive dis-
tention. These minute vessels, so to speak, draw the blood towards them-
selves, and call upon the larger vessels immediately beyond them for an
increase of action; and hence the gradual and progressive development of
the latter from their extremities upwards. It is also of further importance
in pointing out the distinction between the dilated condition of the larger
vessels in this disease, and that which is observed in aneurism proper; the
one being the result of actual growth; the other of inflammation, ulceration,
or of passive dilatation. It might indeed be argued in favour of the passive
dilatation of the vessels in this disease, that their parietes are sometimes
thinner than natural; but this is not invariably the case, and never to such
a degree as to allow their calibre to be dilated to ten times its natural di-
mensions, much less to allow the whole vessel to be increased to more than
three times its natural length. In the case No. 3. the parietes of the ves-
sels were rather thickened than attenuated. The disease, indeed, admits of
an increased thickness of the parietes as well as an increase of calibre, and
an increase in the length of the vessels. In this respect the vessels of the
morbid tissue resemble those of some of the normal structures, which, under
peculiar circumstances, undergo an active development, as in the vessels of
the impregnated uterus, or in those that supply the stag’s horns during their
rapid evolution.

The period at which the disease may extend from the capillaries to the
larger vessels, and take on a rapid development, differs greatly in different
cases; in some commencing almost immediately after birth, in others a few
months later, or at any time during childhood, adolescence, or afterwards.
In the majority of cases, perhaps, the disease never extends to the larger
vessels at all; but after existing in the form of an elevated and discoloured
spot on the surface of the body, as the individual grows up, this finally shri-

Watson’s Oh serrations on Telangiectasis.

vels, and sinks to the level of the skin, and afterwards exists as a mere dis-
coloration; or even the discoloration may be effaced, and the skin present
its natural appearance. The size, colour, and turgescence of these tumours,
vary materially with the state of the general circulation. It is stated that
they are more apt to take on a rapid growth about the period of puberty
than at any other age; but after referring to the history of a great number
of these cases, I am satisfied 4hey are no more liable to active development
at this, than at any earlier period.

The same class of vessels may be involved, and the same train of symp-
toms may follow, whether the disease be congenital, or induced at any
period subsequent to both; and hence the particular period of life at which it
first becomes manifest, affords no sufficient reason for establishing the patho-
logical distinctions which some have attempted between naevus maternus
proper, and aneurism from anastomosis; or between the congenital and the
accidental naevus.

These vascular growths possess but a very low degree of vitality. Du-
puytren, in comparing them with the erectile tissues of normal character,
states that their supply of nervous influence is small. Their sensibility
indeed bears no proportion to their supply of blood; they are not easily irri-
tated or inflamed; and when once inflamed they have a tendency to slough;
and where mortification does not ensue, the inflammation does not readily
extend itself to the surrounding parts of the diseased tissue, and is slow in
passing through its several stages. In the case first related, the potential
and even the actual cautery were several times employed without exciting
actual inflammation to any extent around the immediate spot upon which
they were applied. The same amount of irritation in any of the normal
tissues receiving an equal or any approach to an equal supply of blood,
would have excited much more acute and extensive inflammation. Are we
not then justified in concluding from this fact, that something more than
great vascularity is requisite for inducing inflammatory action even in the
healthy tissues? These, under a given supply of nervous influence, in pro-
portion as their vascularity is augmented, have their irritability exalted,
first within the range of health, but beyond this, to the production of mor-
bid sensibility and actual disease. We are told that in the bones and other
white tissues, inflammation is not readily induced, because their supply of
blood is small. Might we not also add, because their supply of nerves is
equally deficient? Where nervous influence is weak, then, even in the most
vascular tissues, inflammation is not easily excited, nor is it so active in its
progress, or so apt to spread, as under other circumstances. If these points
be admitted, (and the facts above noted are sufficient to establish them,) the
agency of the nerves, in determining the phenomena of inflammation, will
be rendered more manifest, and shown to be of more importance, than has
hitherto been generally acknowledged.

No. XLVIl.- — May, 1839.

38 Watson’s Observations on Telangiectasis,

Breschet* and others, admit that the disease under consideration, may
manifest itself in almost every tissue of the body. “ It is developed,” says
Dupuytren, “in all parts of the body, but most frequently in the lips,
doubtless in consequence of their spongy and vascular structure. It has been
met with on the arm, fore-arm, thigh, scalp, ear, cheek, and organs of gene-
ration; in the tissue of the skin, in the muscles, the periosteum, the bones, the
kidney, the liver, &c.”f One case is recorded by Cruveilhier, and another
by Pelletan, in which this disease is said to have originated in the brain.f

Without questioning these authorities, I must nevertheless observe,^ that
in most of the cases on record bearing intrinsic evidence of belonging to the
disease under consideration, the morbid growth has had its origin either in
the common integuments, the mucous membrane, or in the cellular tissue.
Doubtless it may originate in other textures, as in the case quoted from
Breschet, where it commenced in the thyroid gland; but many of the cases
in which it is said to have occurred in the bones, in the viscera, among the
muscles, <fcc., are, to say the least, equivocal; and no doubt some of them
were of a carcinomatous nature.

The various forms of telangiectisis may be divided; first, in relation to
their seat — into the cutaneous, the subcutaneous, and the mixed; secondly,
in relation to the class of vessels affected — into those involving the capilla-
ries only, those extending to the arteries, and those extending to the veins.

Is^. Of the Cutaneous Ncevus, — This is the simplest form, and the one best
known to the profession. It is almost invariably congenital, and is manifest
either at birth, or within a few days afterwards. In some few instances,
however, it originates spontaneously at a much later period. A few years
ago, I observed for the first time a bright red spot, on my own face. For a
length of time it appeared to be a mere point; this gradually increased in
size, and two or three similar points, not quite so superficial, were to be ob-

* Memoires de la Academie Royale de Medecirie, tome iii. p. 128. In his essay pub-
lished in this work, Breschet refers to the Repertoire d’ Anatomic, tome i. for 1826,
in which he records a case of this disease originating in the bone. This case I have not
the means of referring to, but I am informed by my friend John Hamilton, Esq. of Dub-
lin, that after studying Breschet’s case attentively, and the cases which he quotes from
Dupuytren and others, as aneurism by anastomosis in the bone; he is convinced they
were of malignant character, “ obviously fungus hematodes” — and his opinion is confirm-
ed by a similar avowal, made to him in relation to the same cases, by Mr. Hodgson of
Birmingham. The impression existing in France, even up to the present time, in rela-
tion to these two very distinct forms of disease, is sufficient to account for Breschet’s mis-
application of the term “ aneurism by anastomosis,” — and the same may also apply to
some of the cases of erectile tumours of Dupuytren. Dr. Bushe, I conceive, has com-
mitted a similar error in a case which he relates as telangiectasis originating in the me-
dullary cavity of the tibia. The case has to me more of the character of the malignant
fungus. See the New York Medico-Chirurgical Bulletin, vol. i. p. 59.

t Leqons Orales de Clinique Chirurgicale, tome iv. p. 51.

X Mentioned by Bushe. Loco citat. p. 65, from Cruveilhier, Anatomie Pathologique,
tome ii. p. 133 — 83. Pelletan, Clinique Chirurg. tome ii. p. 76.

Watson’s Observations on Telangiectasis. 39

served about it; the whole giving a slight elevation to the skin, and feeling
like a little pimple or fine grain of sand under the finger. Some months
ago I punctured the principal spot with the point of a needle. It bled for
half an hour, and continued dripping slowly afterwards for several hours;
the single puncture must have given exit to more than two drachms of
blood; and since that time the spot has somewhat diminished.

These nsevi are, at birth, unattended with any tumefaction; hut as the
child grows the discoloration spreads, and sometimes the spot becomes
elevated above the level of the skin. Continuing to increase, it demands
an additional supply of blood, and the vessels leading to it are consequently
increased in size, and the temperature of the part is greater than natural.

The cutaneous neevus has rarely a strong pulsatory movement, but still a
feeble thrill may be at times very perceptible on pressure. After continuing
to spread for some time, it may become stationary; and finally, falling to the
level of the skin, exist afterwards as a mere stain upon the surface; or con-
tinuing to increase, it extends to the subjacent tissue, and thus constitutes
what may be called the mixed form.

'2d. Of the Mixed Nsevus. — The subcutaneous cellular tissue becoming
involved, the disease now produces more deformity, elevating the integu-
ments in the form of a soft bosselated tumour. The original cutaneous spot
still exists in the centre; but the rest of the swelling is marked by no dis-
coloration, or at most, only a faint tinge of purple or red; caused by the
colour of the subcutaneous portion of the tumour striking through the
healthy integuments. The swelling now communicates a whizzing or
vibratory movement to the finger when pressed upon; the blood is easily
forced out of it; but, on removing the pressure, the swelling soon regains
its former size. The veins in the neighbourhood of the tumour are some-
times observed to be much fuller and larger than natural, and the arteries
also in some cases beat strongly over a great extent of surface. The integ-
uments occasionally ulcerate, and the patient is then subject to hemorrhage
from the slightest abrasion of the surface. Sometimes the whole tumour,
ulcerating or becoming inflamed, sloughs away, and a spontaneous cure is
the consequence.

^d. Of the subcutaneous Nsevus. — This possesses all the characteristics
of the last, except that it does not originate in the skin, or even extend to
it. This swelling, too, is moveable at first, and appears to be covered by a
proper coat of dense cellular tissue. The pulsation in it is not generally
very strong, and sometimes is not to be felt at all. The irritation produced
by it among the surrounding tissues, as in the case of the mixed naevus, may
excite inflammation, ulceration, or even destructive action; and these morbid
changes extending to the surface, necessarily give rise to frequent hemor-
rhage; or progressing in other directions, injure or destroy the muscles,
fasciae, and even the bones themselves.

40 Watson’s Observations on Telangiectasis.

The divisions of telangiectasis founded on the particular class of vessels
involved, are the most proper for illustrating the anatomical structure of the
various tumours grouped under this head.

Telangiectasis of the Capillaries. — It is probable that in the majority of
these spots, whether cutaneous or deep-seated, the niinute arteries and veins
next in order above the capillaries, are also more or less affected. It is onl^^
therefore in cases where important vessels participate in the disease, that
we must refer the tumour from this to the other varieties. When the ca-
pillary naevus is examined, it is found to be seated sometimes in the venous,
sometimes in the arterial portion of these vessels, and sometimes affecting
both. Its colour is modified according to these circumstances, being of a
brighter or darker hue, according as the arterial or venous blood prevails
in it. When the swelling is cutaneous, the vessels themselves constitute
the great mass of the nasvus; for here the cellular tissue is not found in suf-
ficient quantity to form any important portion of it. But when the tumour
lies in the loose tissues beneath the surface, the enlarged and elongated ca-
pillaries are bound together by a matrix of cellular tissue; and they are
often so much dilated and contorted as to form irregular cells of themselves.
Some have indeed described them as being composed of cells into which
enlarged vessels enter. “ The tumour,” says Bell, “ is composed of small
and active arteries, absorbing veins, and intermediate cells. The irritated
and incessant action of the arteries fills the cells with blood: from these cells
it is re-absorbed by the veins: the extremities of the veins themselves per-
haps dilate into this cellular form.”* Mr. Wardrop in describing a subcu-
taneous naevus, states that “ the boundaries of the tumour appeared distinct,
some healthy cellular membrane surrounding it, which was traversed by
blood-vessels. On tracing these vessels to the diseased mass, they pene-
trated into a spongy structure composed of numerous cells and canals of a
variety of forms and sizes, all of which were filled with the injection, and
communicated directly with the ramifications of the vessels.” Several of
the vessels, he states, from the thinness of their coats, appeared to be veins
much enlarged, — and some of them sufficiently big to admit a full sized
bougie. “ These cells and canals had a smooth and polished surface, and in
some parts resembled very much the cavities of the heart, fibres crossing
them in various directions like the columnse tendin3e.”j' More recent ob-
servers state that this cellular appearance is deceptive, produced by the
particular mode in which the tumours have been examined, and by the
irregular shape, size and course of the vessels themselves. That they are
almost entirely composed of arteries and veins, has been proved by Mr.
Sheckleton, who injected them with wax, and afterwards corroded the soft
materials, so as to show the true form and course of these vessels.:];

* Principles of Surgery. By John Bell, vol. iii. p. 386. London, 1826,

t Medico-Chirurg. Transact, vpl. ix. p. 204.

t See a notice of Mr. Sheckleton’s preparations, Dublin Journal, vol. viii. p. 219.

Watson’s Observations on Telangiectasis. 41

Telangiectasis extending to the larger Arteries. — In many of the cases
on record, the larger vessels have become diseased only after the capillaries
have existed in a morbid condition for a number of years. In other cases,
however, there appears to have been a congenital weakness of these vessels,
co-existent with an evident disease in the capillaries: such was probably the
fact in sortie of the cases of Breschet to which I have already alluded. The
diseased arteries are sometimes simply dilated; sometimes they present great
irregularity as to their calibre, their length, and the thickness of their pari-
etes; and in almost all cases they are convoluted, or rolled upon themselves;
sometimes constituting a mesh of vessels united together by cellular
tissue, so as to present a soft fluctuating and pulsating tumour, which, by its
growth and constant action, produces disturbance in the surrounding parts;
sometimes winding along the limb in an irregular course, as in varix of the
lower extremities, without forming any distinct tumour, or congeries of ves-
sels. It has been supposed that the vessels in this disease form more fre-
quent anastomoses than in their healthy state; such, however, has not been
proved to be the fact, and some who have written on this subject, have
denied it.

Telangiectasis extending to the larger Fei/is.— Instances of the disease
extending more particularly to the veins than to the arteries, are by no
means frequent. The veins, it is true, are generally enlarged in cases
where the arteries are dilated; but not to so great an extent. Case X. is an
instance of this disease in which the veins were principally affected. The
appearances presented are nearly the same as in ordinary varix.

Diagnosis. — The diseases with which telangiectasis is most liable to be
confounded, are different according as it is superficial or deep-seated, and ac-
cording as it affects the capillaries only, or extends from these to the larger
arteries or veins. It may be mistaken for aneurism proper; for varix; for
aneurism by erosion, or the aneurism of Pott as it has been called by the
French; for cephalsematoma or the bloody tumour occurring on the head of
new-born infants; for encysted or other non-malignant tumours; and for
Tungus hematodes.

With aneurism proper, Breschet has indeed grouped one of the forms of
this disease, viz. that in which the dilatation is extended to the arterial
trunks, calling this the cylindroid aneurism when the calibre of the artery
is dilated regularly, and circoid aneurism when the dilatation is irregular
and the vessel tortuous and nodulated. But the gradual progress of the dis-
ease from the smaller to the larger vessels, the co-existence of nasvi from
which the dilated vessels appear to emanate, the want of coagula in the dila-
ted trunks, their tortuosity, and the irregularity in the thickness of their
parietes, independent of inflammation, ulceration, rupture, or cartilaginous
or earthy deposit; not to speak of the age and class of patients most frequently
affected; may be sufficient to characterize this disorder. But in those per-
sons, in whom the parietes of the arteries are thinner than natural, it is pro-

42 Wa,ison's Observations on Telangiectasis.

bable that causes, insufficient to excite proper aneurism under ordinary cir-
cumstances, might here induce it; and thus the two disorders might be
found C07existing in the same subject. Again, in some cases of aneurismal
varix, the disturbance in the circulation, produced by the unnatural commu-
nication between the artery and vein, may lead to irregular dilatation, twistr
ing and elongation of these vessels. But in all such cases the causes of
these changes must be sufficiently apparent.

The varicose state of the veins produced by stasis of blood, or by inter-
rupted circulation in these vessels, as seen in the lower extremities, and
sometimes in other parts, (as in the spermatic cord,) might be mistaken for
this disease. The freedom from cutaneous nsevi or from pulsating tumours^
the age' and habit of the patient affected with varix, its seat, and its excit-
ing cause, are sufficient to distinguish it. The disease sometimes called
Pott’s disease of the leg; sometimes the aneurism of Pott, or aneurism by
erosion of the artery, may be mistaken for some of the severer forms of
telangiectasis. Cases of the disease now referred to, are given by Pelle-
tan,* * * § Hodgson,t and others: and as I have never verified it by dissection*
I must refer to Potts’ original description of it.ij:

The only case of cephalaematoma, that has fallen under my observation,
might have readily been mistaken for a subcutaneous nsevus. The tumour
was seated over the sagittal suture, was as large as a pullet’s egg — ^it
existed at birth, and the integuments over it were of their natural character*
The tumour, however, did not throb; and though it had a soft doughy and
inelastic feel, it could not be diminished by pressure; and no enlarged ves-^
sels were observed in its neighbourhood. §

The subcutaneous neevus may be mistaken for encysted and other tumours.
The thrilling or pulsatory movement of the nsevus, the ease with which it
may be diminished by pressure, and its almost immediate return to its for-
mer size when the pressure is removed, will distinguish it from these.

In some cases of superficial nsevus where the integument has ulcerated,
and the disease is shooting forth in the form of a spongy tissue, bleeding at
the slightest touch, it may be difficult to distinguish it from fungus hema-
todes. But the early history of the case, the strictly local character of the
disease, its continuance for years without involving the general health fur-
ther than by the loss of blood which it may occasion, or by the pressure and
consequent disturbance which it may cause in the adjacent tissues; the ab-
sence of carcinomatous growths in other parts of the system, and the im-

* Clinique Chirurgical, tome ii. p. 37. et seq,

t Treatise on Diseases of the Arteries and Veins, p. 448, et seq.

X Surgical Works, voL ii p. 321. Philadelphia, 1819.

§ See Bushe’s paper on “ Hematoma of the head in new-born children,” in the New
York Medico-Chirurgical Bulletin, July, 1831. Also, a monograph on the same subject,
by Prof. E. Geddings, in the American JournaLof thejMedical Sciences for Feb. 1839.

Watson’s Observations on Telangiectasis*

munity of the patient from all chance of its recurrence after having been
once fairly removed; are sufficient to distinguish it from fungus hematodes.

Causes. — Boyer has divided this disease into two kinds, the one congeni-
tal, the other accidental. In the great majority of cases the derangement
in the vascular structure which constitutes this disease, is attributable to a
primitive defect in the organization of the capillary vessels, and perhaps also
in some of the vessels of larger size. That form of telangiectasis which
involves the arteries, and which is marked by strong pulsation, and rapid
and obstinate growth, is, I believe, the only one that has been described as
occasionally resulting from local injuries. Travers and Dairy mple recite
cases in which this form occurred spontaneously within the orbit in females
during pregnancy. Long continued pressure, severe blows, and various
kinds of local irritation, have been advanced among the exciting causes.

Prognosis. —The. danger to be apprehended from naevi varies with their
size, their seat, the class of vessels principally involved, and the rapidity of
their growth. When confined to the skin, unless undergoing rapid devel-
opment, or becoming ulcerated, they require no special attention. When
seated in the subcutaneous cellular tissue, or when they extend to this from
the surface, and especially when the vessels leading to them are much en-
larged, they never entirely subside of themselves; they may continue to
grow for years, and then either become stationary, or by exciting irritation
in the surrounding tissues, produce caries of the bones, or ulceration of the
soft parts; and by frequent and profuse hemorrhage, finally exhaust the
patient.

Treatment. — The treatment applicable to the different forms of telangiec-
tasis has, within the last thirty years, been the subject of much speculation
and experiment. Without attempting to dwell upon the various operations
that have been suggested, and all of which have been practised with more
or less success, we may remark, that they have hitherto been devised for
fulfilling either one or more of the following objects:

1st. To prevent the undue ingress of blood, and thus to allow the morbid
growth to contract to its natural: condition.

2d. To remove the diseased tissue, and to allow the wound or ulcer, thus
left, to cicatrize.

^d. To induce a change of action in the diseased tissue, by which it may
be consolidated and deprived of its undue supply of blood, and thus allowed
to assume its natural appearance and character.

The means employed for fulfilling the first of these objects, are, for the
most part mechanical; and act either by compressing or constringing the dis-
eased. vessels, or by cutting off the channels through which they are princi-
pally supplied with blood. The means for fialfilling the second object, are
destructive: among them, are grouped excision, caustic and corroding appli-
cations, and the ligature en masse. Those for effecting the third object are
physiological i and have been instituted for exciting inflammation and the

44 W atsori^s OhsermtioM on TeldngiectasU*

consequent effusion of coagulable lymph within the diseased structure; and
thus, on the subsidence of- the inflammation, to reduce the vascularity of the
part. Among these means may be enumerated, 1st, the introduction of the
cataract needle for lacerating the central portion of the tumour: 2d, the in-
troduction of heated needles: 3d, vaccination and the production of artificial
pustules immediately over the diseased mass: 4th, injection of stimulating
liquids among the diseased vessels; and, lastly, the introduction of the seton
beneath them.

Isjf. By Compression.-^This is rarely or never employed for removing
the cutaneous nsevus; and for the deeper forms it is generally a tedious and
uncertain means of cure. Bell has staled that compression tends rather to
aggravate than to remove these swellings; yet in the hands of Pelletan,
Boyer, Roux, and Dupuytren, this mode of treatment has been occasionally
successful. A striking example of its efficacy is related by Boyer. His
patient, an infant, had a pulsating tumour near the lower part of the septum
of the nose; the position being such as to prevent complete extirpation, he
advised the mother to foment the tumour with alum water, and to press it
between the thumb and finger as often as she could. I attached, says he,
but little importance to this advice. It was followed, nevertheless, with all
the perseverance that maternal tenderness could inspire, the mother often
spending seven hours at a time in compressing the spot without removing
her fingers. This perseverance was followed by success so complete that
in August, 1809, having been consulted anew concerning this young person,
now twelve years old, it was impossible, he observes, to recognize any re-
mains of the tumour.*

2d. By Pressure and Cold combined. — This practice was first instituted
by Abernethy. Finding that, in some forms of the deep naevus, the tem-
perature of the swelling was greater than natural, he concluded that the dis-
ease was owing to “ a kind of inflammatory action of the surrounding arte-
ries,” and therefore resorted to these means as the most applicable for
diminishing the tumour and reducing this action. His first case was one of
mixed nsevus, complicated with great enlargement of the vessels over the
hand and forearm. A manytailed bandage of sticking plaster was applied
over the limb, and the whole kept moist with cold water. Whatever we
may think of the pathology upon which this practice is founded, we cannot
question its success. In six months from the time of commencing treatment,
the disease was cured. He relates another case treated successfully by cold
alone. The naevus projected from the orbit, closing the eye, and forming a
tumour as large as a walnut. “ Pressure, to any extent was here evidently
impossible; but the abstraction of heat, and consequent diminution of inflam-
matory action, might be attempted.” He therefore recommended “ that
folded linen wet with rose water saturated with alum, should be bound on

* Maladies Chirurgicales, tome ii. p. 382. Paris, 1831.

Watson’s Observations on Telangiectasis. 45

the projected part, and kept constantly damp.” At the end of three months
the tumour had shrunk within the orbit, and the child could open its eye.* * * §
^d. By Ligature to the Artery supplying the Tumour. — This process is
applicable only to those severe forms of nmvus or aneurism from anastomosis
in which other means have failed, and in which the disease has extended from
the capillaries to the larger vessels, particularly to the arteries. Pelletan
was the first to institute this practice. His case I have already quoted —
(see Case XL) The carotid artery was first successfully taken up for the cure
of this disease by Mr. Travers;f afterwards by Mr. Dalrymple;ij: and since
these operations several other successful cures, have been recorded. In not
a few instances, however, this practice has been unsuccessful in removing the
disease; and in several cases it has been the immediate cause of death. —
Bushe relates a case of extensive and increasing nsevus in an infant between
six and seven weeks old, for the cure of which, without attempting any other
previous treatment, he took up the common iliac artery. The child lived
about five weeks after the operation. § Judging from the cases on record, in
which the larger arteries have been taken up for the cure of these tumours,
we may fairly conclude that much harm has been done by rashly resorting
to this practice; that it should never be attempted until other means have
failed; and then, only when the urgency of the case is sufficient to warrant it.
The danger of operations on the brachial or femoral artery, or their imme-
diate branches, for pulsating naevi, is not usually so great as operations on the
carotid, or the larger vessels of the trunk. But even operations on the large
vessels of the limbs are sometimes insufficient to arrest the growth of these tu-
mours. Mr. Lawrence relates a ease of aneurism by anastomosis on the finger
in a woman twenty-one years old; the disease was congenital. In 1815, Mr.
Hodgson, finding that the beating could be arrested by pressure on the radial
and ulnar arteries, attempted to cure the disease by tying these vessels. The
immediate consequences of the operation were a cessation of the beating,
collapse of the swelling, and relief from the pain; but these symptoms all
recurred in a few days, and were just as bad as before. Mr. Lawrence
finally cured the patient by making a circular incision through all the soft
parts of the finger above the tumour, excepting the flexor tendons with their
theca and the extensor tendon; and afterwards allowing the wound to heal
as an ordinary cut. In this case the digital artery was found equal in size
to the radial or ulnar of an adult, and was the principal nutrient vessel of
the disease. 11

^th. By Excision. — The mode of destroying naevi by excision was recom-
mended and practised by J. L. Petit, and has been in general use ever since

* Abernethy’s Surgical Works^ vpl. ii. p. 37. Hartford, 1825,

t Medieo-Chirurg. Transactions, vol. ii, p. 1.

X Ibid. vol. vi. p. 111.

§ New York Medico-Chirurgical Bulletin, vol. i. p. 54,
j] Medico-Chirurg. Transac, vol. ix. p. 216,

Watson’s Ohsenations on Telangiectasis,

his time. In the cutaneous nsevus, of no great size, it is the most effectual,
the readiest, and least painful practice. It is not, however, applicable to
very large nsevi. In the subcutaneous nsevus it has been followed by fatal
hemorrhage; and it is altogether improper in those forms of the disease
which are complicated with extensive dilatation of the larger vessels. In
resorting to excision for the removal of these tumours, in order to avoid
hemorrhage as much as possible, it is important to carry the incision through
the healthy tissues surrounding them, and not into the diseased mass.

Mh. By Caustic Applications. — In the small cutaneous naevus, where a
slight and single application of caustic may be sufficient to destroy the spot,
as in the spider n^vus; and especially when such spots are situated on parts
of the body where the cicatrix left by the application may not disfigure the
individual, this practice may be employed with advantage. It is rarely ad-
visable in extensive naevi, never in those that are deep-seated, or connected
with enlargement of their nutrient vessels. Dr. Hosack informs me that he
has seen the caustic potassa applied to a small nsevus on the side of the nose,
and the effect of it was so severe as to completely destroy the cartilage, and
expose the cavity of the nostril. The great objection to the use of caustic
applications is, that the extent to which they act can never be precisely re-
gulated. When applied cautiously they often fail in effecting a cure; and
sometimes, merely destroying a part of the morbid tissue, they allow of fun-
gous growth and frequent hemorrhage from the part remaining.* * * §

Various caustic applications have been used, as quick lime and soap in
equal parts, j* the butter of antimony ,:f potassa,§ nitrate of silver, the mineral
acids, tartar emetic ointment. In short, any corroding application may be
employed for the purpose.

Qth. By the Ligature en masse. — I’lie application of ligatures for the pur-
pose of arresting the circulation in these tumours, and allowing them to
slough, was suggested, if not practised, by J. Bell. Pelletan has also re-
corded a case in which he applied it;]] but the attention of the profession was
first particularly directed to this important means, by the success attending
it in the hands of Mr. Anthony White.1T It is applicable to the elevated and

* Boyer, Maladies Chirurgicales, tome ii. p. 395. Paris, 1834.

t Recommended by Callissen. See Cooper’s Dictionary.

t Pelletan, tome ii. p. 76, states that, while he was a pupil, he had seen this caustic
application used, in a severe case of varicose tumour of the head, by M. Moreau. The
patient died; and, on examination, it was found that the pressure of the tumour, growing
from within, had produced an obliteration of the frontal bone, and through the openings
in the bone the corroding liquid had entered, and excited extensive inflammation of the
dura mater and parts within the skull.

§ Used by Pelletan, tome ii. p. 69. Mr. Wardrop, however, has the credit of being the
first to employ this and the nitrate of silver extensively and with success.

II Loco citato, p. 71,

f Medico-Chirurg. Transac, vol. xiii. p. 444, See also this Journal, vol. ii. p. 220,

Watson’s Observations on Telangiectasis,

subcutaneous nsevus. The ligature should be introduced doubled, by means
of a needle, under the base of the nsevus, and should be drawn sufficiently
tight to arrest the circulation in every part of the diseased tissue. The prin-
cipal inconvenience attending it, is the excessive pain, (which is sometimes
so severe as to excite convulsions,) after the ligature has been tightened. —
In cases where the tumour is entirely subcutaneous, much of this suffering
may be avoided by the practice recommended by Mr. Liston, which consists
in dividing the integuments by a crucial incision over the. swelling, dissecting
back the flaps, and applying the ligature around the base of the tumour with-
out including the skin.* * * § The ligature is generally allowed to remain until
the nmvus has sloughed; but in some instances it has succeeded, even though
removed before disorganization had commenced.!

7th. By Lacerating the Morbid Tissue. — This practice was introduced,
and successfully employed, by Dr. Marshall Hall;! and has succeeded in
other hands. It consists in puncturing the neevus with a cataract needle, and
carrying the blade of the instrument in various directions through the tumour-
After withdrawing the needle, pressure is to be applied for forcing the blood
out of the diseased part. The inflammation following this process is in some
cases sufficient to effect a cure without causing a cicatrix, or leaving any de-
formity. It is applicable to the cutaneous, the small subcutaneous, and the
mixed nsevus.

Sth. By Vaccination and Factitious Eruptions. — Vaccination for the pur-
pose of exciting inflammation in these spots, was first proposed by Mr. Hodg-
son ;§ and in some cases of cutaneous naevus it is sufficient to effect a cure.
The virus should be introduced at several points around the base and over
the surface. Where vaccination has already been performed, and the patient
is no longer susceptible of its influence, Mr. Young, of Glasgow, j] has recom-
mended antimonial ointment, with the view of producing an eruption, and
effecting a cure in the same way as with the vaccine virus.

9^/i. By the Cautery Needles.- — The first notice I find of this practice is
in a case in which Mr. Macilwain employed it unsuccessfully. The case was
one of subcutaneous naevus. He endeavoured to excite inflammation by pass-
ing red hot needles through its substance. “ These measures were repeated
thrice at intervals of about a week; each puncture was followed by a single
jet of arterial blood, and produced considerable constitutional disturbance,
which continued for about tw*enty-four hours; but they were followed by no
diminution of the tumour, which, on the contrary, increased slowly but pro-

* British and Foreign Medical Review, vol. iii. p, 557.

t Lawrence, in the Medico-Chirurg. Transac. vol. xiii. p. 436.

t London Medical Gazette, vol. vii. p. 677.

§ Medico-Chirurgical Review, July, 1827, p. 280. See also this Journal for April, 1828,
p. 170. Also, Lancet, vol. xii. p. 604 and 760, and London Med. Gaz. vol. iv. p. 32.

II Glasgow Medical Journal, vol. i. p. 93. See also this Journal, vol. ii. p. 460, and vol.
XV. p. 251.

48 Watson’s Observations on Telangiectasis,

gressively.”* * * § ** The late Dr. Bushef has reported several successful cases of
small cutaneous naevi treated in this way; but in the case which I have re-
lated at the commencement, he had completely failed. In his published
cases he recommends a common cataract needle heated to whiteness; he af-
terwards employed a fine piece of steel, with a blunt point, and mounted on
a handle. The great objection against these small cautery needles is, that
they do not retain their temperature for a sufficient time; they lacerate rather
than cauterize the tumour, and do not excite inflammation to any great ex-
tent around the immediate point at which they are introduced.

IQtk. By Injection. — So far as I am aware, Mr. Samuel Cooper first pro-
posed this practice. It was first successfully employed by Mr. Lloyd.;}: The
injection consisted of from three to six drops of nitric acid dissolved in a
drachm of water; it was thrown into the tumour, by means of a syringe, through
a minute puncture near its base. During the operation careful pressure was
made in all directions round the tumour, to prevent the fluid from entering
the general circulation. The next case on record, in which this practice was
employed, was attended with an instantaneously fatal result. §

l\th. By the Seton. — For this practice we are indebted to Mr. Faudington
of Manchester.}] It has also been employed with marked success by Mr.
Macilwain, in cases of deep naevus, where no other mode of treatment could
have been advantageously employed. It has also succeeded, under similar
circumstances, in the hands of Mr. Carmichael, IF M. Lallemand,*^ and in Dr.
A. H. Stevens’s case, which I have already reported. It does not appear to
answer so well for the cutaneous naevi as for those that are situated in the
tissues beneath the skin. In resorting to this practice the seton should be
passed completely under the tumour, and not into its spongy texture; other-
wise it ulcerates through the morbid mass before exciting inflammation suf-
ficient to consolidate it. In the cases reported by Mr. Macilwain, as well as
in that of Mr. Carmichael, several setons, consisting of silk threads, were
passed in different directions under the swelling ; in Dr. Stevens’s case, a
single seton only was employed; and in all of them the threads were allowed
to remain until free suppuration was established, and the tumour itself had
undergone a change of character; a process which, under different circum-
stances, may require for its completion from a few weeks to three or four
months. The advantages of this practice are, that it is attended with little
or no danger; that it may be employed in many cases where other means
are inadmissible, and that no permanent deformity is left by it.

* Medico-Chirurg;. Transac. vol. xviii. p. 193.

t New York Medico-Chirurgical Bulletin, No. 2.

t London Med. Gazette, vol. xix. p. J4, Oct. Isl, 1836.

§ Ibid. Dec. 30th, 1837.

II See Mr. Macilwain’s paper in the Medico-Chirurg. Transac. vol. xviii. p. 189.

IT See a notice of Mr. Carmichael’s Case in the Dublin Journal, vol. viii. p. 219.

** Observations Relatives k Divers Precedes Operatoires employes centre les Tumenrs
Erectiles: republished from the Archives Generales de Medecine.

Bartlett’s Case of Chronic Cerebral Affection,

Art. III. Chronic Cerebral Affection: long continued, intense headache:
double consciousness: extraordinary memory of events: ineffcacy of
treatment: diagnosis doubtful. By Elisha Bartlett, M. D., Professor
of the Theory and Practice of Physic, and Pathological Anatomy in
Dartmouth College.

The following case has appeared to me to be one of sufficient import-
ance to justify me in presenting it to the public. The report of it may
possibly seem to the reader to be unnecessarily prolix and minute, but I
did not see how it could well be made less so, without sacrificing that com-
pleteness, and fulness of detail, upon which the interest, and the value itself,
of the case depends. The present would be a very proper place for some
general remarks on the subject of chronic cerebral disease. There is no
single department of pathology, which offers to the scientific inquirer pro-
blems so surrounded with difficulties, and yet so filled with interest as this,
but as the report of the case occupies so much room, I shall simply present
it to the reader, omitting, at least for the present, all note or comment^
either upon the case itself or upon the general subject to which it belongs^

April l^th, 1838. — R. M , the subject of this case, was 15 years

old in October, 1837. She was born in England, and came to this country
about seven years ago. She has a fair complexion, light hair, is conside-
rably fleshy and fat, and has a pretty large, well developed head. She is
good tempered, and is intelligent for a girl of her age and education. She
enjoyed uniform and excellent health, till she was thirteen years old. She
then menstruated, and at that time began to complain of headache, and of pain
in the back and limbs. The pain in the back and limbs soon went oflT, but
the headache continued. During the first year it was not constant, although
she had more or less of it nearly every day. This pain gradually became
more constant and more severe, and since the close of the first year, she has
never for a single moment, so far as can be ascertained, been free from it.
Until the expiration of the first year, she was able to work part of the time
in a woollen mill, and a part of the time she was at school, although she
W'as frequently obliged to leave both her work and her school on account of
the severity of the headache. The seat of the pain has always been through
the head, from the forehead to the occipital. She never feels it at the top or
at the sides of the head. It never changes its seat; it never intermits. It
has not done so for the last year. It is very much more severe at some
times than at others. Generally, though not invariably, it grows worse as
the day progresses.

There has been moderate intolerance of light and sound from the begin-
ning. This is pretty regularly increased in degree with the increased se-
verity of the pain. It is never, however, excessive. The vision has not
No. XLVII-— May, 1839. 5

50 Bartlett’s Case of Chronic Cerebral Affection.

been much affected. It is rather feeble, but correct. On looking steadily
at an object, it grows dim and indistinct. There is frequently some ringing
in the ears. The sound oftenest heard is that of running water. Epistaxis
has been pretty common for the last year. During the two past weeks, it
has occurred every day, and has, some days, been repeated several times.
It almost always occurs in the day time, oftenest in the latter part of the
day, continues pretty freely five minutes or so, and is never attended or fol-
lowed by any mitigation of the pain. Within a few weeks she has com-
plained of some numbness of both feet and of both hands: that of the feet
is greatest. This numbness comes on several times a day, remains fifteen
or twenty minutes, and then goes off. Occasionally she feels a pricking sen-
sation, especially in the hands. Once, some weeks ago, while walking across
the floor, she fell.

The mind has been perfectly free, till within six months. She has become
somewhat forgetful, but there has not been the slightest aberration. She is
remarkably patient and quiet. There is no fretfulness, and no change of
temper.

The appetite has been poor from the beginning. The quantity of nutri-
ment which she has taken for the last year has been very small, and it still
continues so. There is no emaciation. The bowels are regular, and are
easily moved. The discharges are not very consistent, but sufficiently
healthy in appearance. There is no flatulence, no acidity, no nausea. The
tongue is, most of the time, mode^-ately coated. Thirst is constant and
pretty urgent. Nearly all the time there is a sense of chilliness over the
body generally. Through the head, corresponding to the seat of the pain,
she complains of a burning heat. The hands and feet are constantly cold.
They are white and bloodless, looking like alabaster. The scalp feels hot
to herself and moderately so to the hand. It is also, occasionally, in various
parts tender to the touch. The face is usually flushed, and much more so at
some times than at others. The pulse varies from 76 to 100, and is neither
full nor hard. The urine, for some weeks last summer, was copious and
limpid; since that time it has remained natural. A few weeks ago she had
a short, dry cough, which was principally troublesome on account of the
great increase of suffering which it occasioned in the head. It seemed to
be of a nervous or spasmodic character, and ceased immediately on the ad-
ministration of Prussic acid. It returned once, subsequently, and again
subsided on giving the acid. Up to this time the respiration had not been
affected.

She has always had very bad nights. She has distressing, fatiguing
dreams: and running through them all, and through her disturbed and un-
refreshing slumbers, there is an ever present consciousness of the unremit-
ting and intolerable headache. The vulture never sleeps and never lets
go its hold. She lies with one hand constantly to her forehead, and very
frequently says in a suppressed, moaning tone, “ O dear! my head!” She

Bartlett’s Case of Chronic Cerebral Affection.

speaks in a low voice—usually in a whisper. There is frequent deep sigh-
ing, and occasional yawning.

Until within a month she has been able to sit up and to keep about house,
during the forenoon. She is now wholly confined to the bed, and is unable
to hold up her head without great increase of the pain. She says her head
feels very heavy.

Another strong feature in the history of this case, thus far, consisted in
the effect of treatment. I'his was wholly unavailing. It never mitigated
the severity of a single symptom. More than this, almost invariably the
effect of treatment was to render her worse. The details of the treatment
it is unnecessary for me to describe. The depleting, revulsive, sedative and
anodyne medications were, one after another, and variously combined, re-
sorted to, and all to no purpose. General and local bloodletting, emetics,
active cathartics, blisters, permanent drains in the neck, the cold dash, and
mercurials carried to ptyalism, were all made use of. Preparations of iron,
quinine, arsenic, opium and other narcotics, were tried in their turns with
the same unsatisfactory results.

During the first year and a half, or so, of the disease, [ had felt very con-
fident that the case was one of nervous headache merely; that there was
functional disturbance, — intense, morbid, painful erethism of the brain, but
no structural or organic lesion. Resting in this diagnosis, I had thought,
that the patient would finally recover. But the obstinate persistence of all
the symptoms, and their gradual increase in severity, notwithstanding the
active and various treatment that had been opposed to them, induced me to
doubt the correctness of my opinion. I begun to suspect, very strongly,
the existence of some fixed, organic lesion, in the central portion of the
brain, or in the cerebellum. The age of the patient led me to think that
the disease might consist of a tubercular tumour. But if this were the case,
there should have been, also, tubercular matter deposited in the lungs; and
of such desposition there was no evidence depending either upon local signs
or general symptoms. There were no indications, physical or rational, of
phthisis. The resonance under both clavicles was good, and the vesicular
murmur was soft. There w^as no cough, no expectoration, no pain in the
chest, no hectic, no emaciation.

I shall now continue the history of the case from the date of my first re-
cords, April 10, 1838, to the present time. For this account I rely upon
notes taken, not at every visit, but from time to time, as changes manifested
themselves in the condition of the patient.

April 25th. — There has been little or no alteration in the symptoms for
the last fortnight. The pulse to-day is 80, soft and feeble. The numbness
of the feet is now* nearly constant, and when the numbness goes off it is
succeeded by a headache. Last night, as usual, she was dreaming of dis-
tressing pain in the head.

May 24:th — She is apparently more feeble. She now has, several times a

Bartlett’s Case of Chronic Cerebral Affection,

day, short chills or tremors, consisting of a general and pretty violent shak-
ing of the whole body. They are not accompanied by any increased feeling
of coldness. She has, also, frequently during the day, paroxysms, lasting
half an hour or so, of rapid breathing, or panting. I counted 72 respira-
tions in a minute. There is a quick, quivering motion of the eyelids and
lips. There is occasionally, for a few minutes, loss of consciousness, or
something like it. She is awake, but does not know where she is. The
thirst is still very great. The tongue is clean, bright red, sore, and fre-
quently bleeds. The bowels are rather sluggish. The right leg is some-
what more numb and painful than the left. Tears are now and then forced
from her eyes by the excessive -severity of the headache. For some weeks
past she has not kept her hand to her forehead: she says she is too weak to
do so. Pulse, 72.

May 2Qth, — The respiration is now quiet and regular. She does not speak,
except in the faintest possible whisper, and very reluctantly then. She says
that the act of speaking hurts her head — that it feels as though something
struck it, like a hammer. The epistaxis continues, and occurs, usually, just
at night.

June ^th, — For several days past she has not spoken at all. The only vo-
luntary motion which she makes, consists of a slight movement of the fore
finger of one hand, when she wishes for a drink. She does not open her
eyelids. When the eyeballs are exposed, they are seen very forcibly
rolled up in the sockets, constantly agitated with a rapid tremulous motion.
She is unable either to move or to support her head. The head is warm;
the hands and feet still pale, cold, and moist. The thirst is still urgent; the
urine continues free. She had her menses about a month ago. There has
been less epistaxis for several days. She hears very quick, as is evident
from her noticing conversation that is carried on in the room. She does
not notice any thing said directly to herself but very frequently smiles
at remarks directed to some one else. Her mother thinks that she can-
not see.

She was visited and examined a few days since by Mrs. T. a somnambu-
list. Mrs. T. says that the tongue and throat of the patient are sore, for
which she must use alum and marsh rosemary: that the head is diseased,
but not primarily; and that the original disease is a kind of a cancer, — but
not a cancer — situated between the stomach and lungs. She prescribed,
further, shaving and blistering the scalp, blisters to the ankles, friction, from
the hips downwards, and bathing with brandy.

June ZOth. — The patient remains in nearly the same state, except that for
about three weeks she has had, pretty regularly every day, and several
times a day, the severe rigors or attacks of general shivering. She, also,
frequently clenches her hands suddenly together, and throws them violently,
with a motion that seems to be half voluntary and half spasmodic, over her

Bartlett’s Case of Chronic Cerebral Jlffection,

head upon the pillow. This motion is accompanied with an expression in
the countenance of great suffering. The hands and arms are invariably
suffered by the patient to remain in the position above tbe head: she never
removes them herself. The bowels have occasionally required moving with
gentle medicine.

July \2th. — On the 4th July, the patient was found in the morning talking,
in a low whisper, to herself. She had not spoken a syllable before for a
month. She answered readily, in the same low tone, when spoken to. She
said she did not know why she could not talk during the month. She said
the pain in the head was not quite so had. She now and then laughs very
loudly and heartily without any apparent cause. The violent motion of the
arms and hands, already noticed, has become more general, and she throws
herself with great force from one side of the bed to the other. These are
most common in the afternoon. The shivering fits have occurred most fre-
quently in the forenoon.

It has become perfectly evident, since the patient began to talk, that there
are, so far as the brain and its mental manifestations are concerned, two very
distinct and different states. One may be called the natural and the other
the preternatural condition. During the first she appears very much as she
has during the course of the disease. She is then perfectly herself. She
lies very quietly upon her back, occasionally sighing, with a quick, half
spasmodic inspiration, indicative of pain, and occasionally affected with a
short transitory rigor or shudder. Her countenance is composed and sad,
but she rnakes no complaint, unless it is to say, as she frequently does, “ O,
my headP'' She answers questions readily, describes all her sensations, and
is perfectly conscious of every thing about her. During the preter-
natural condition, the whole scene is changed, and various phenomena
of a character somewhat singular are exhibited. It is during this state,
that the fits of throwing herself from one part of the bed to the other
occur. It is also during these fits only that she talks, at other times
never speaking except to answer a question, or to state somewant, or to give
utterance to the sense of pain. It was observed, by her mother, that
when she commenced talking on the morning of the 4th, her con-
versation was wholly upon subjects with which she was familiar before
she left England. It should be stated, that some peculiarities about her
memory had been noticed by her mother, for several weeks. She was first
confined to her bed, up stairs, and she had subsequently been removed to a
lower room. She never could recollect how or when she came down stairs.
On asking her mother, one day, how long her daughter had been confined to
her bed, she referred me to the patient herself, and added, that she could tell
me how many weeks she had been sick and how many visits I had made to
her. I questioned her as to the latter point. She answered, immediately,

54 Bartlett’s Case of Chronic Cerebral Affection*

“ this is the fifty -second.'^'* On referring to my books, I found forty-eight
visits charged, and I had seen her a few times, I cannot say positively how'
many, without making any charge. I then asked her when Mrs. B. called
to see her: she said, ’■'four weeks ago to-day f which was true. The fits of
tossing herself violently about, of which I have spoken, continued with but
little interruption, for several hours, the day before yesterday. The next day,
they commenced at half past five, in the afternoon, and continued five hours.
They were present three or four hours in the forenoon of to-day, and they
again occurred in the afternoon. During the presence of these paroxysms,
day before yesterday, she commenced talking about the scenes of her early
life. She narrated, minutely, circumstantially, and correctly, a great many
occurrences of her earliest childhood. Her mother said she had told almost
every thing that happened to her while a child. For instance, at the age of
two years, her father bought for her a pair of small ear-rings. After wear-
ing them for a short time, they were missing from her ears. She had been
at play alone in a yard, or field, near the house, and the parents never knew
whether the child had lost the rings from her ears, or whether some one had
stolen them. Her father took her in his arms, and carried her into a cer-
tain part of the field, which he distinctly recollects, to endeavour to find
them. Yesterday, she related, and repeated, again and again, all the cir-
cumstances connected with this event. She said that a person took the
rings from her ears — that her father took her into the field to seek them,
and that when her mother carried her to the doctor to have her ears bored,
she cried, like a child, which she would not do again. She also said, that
once when her mother was sick, she herself was rocking the cradle, that
her grandmother came in and told her she need not rock it any more, but
that she might go to her house. She said she went and they had light pud-
dings for dinner. At this time she was three and a half years old. All
these circumstances are recollected by one or by both her parents, and there
is no doubt as to the precise dates of their occurrence. I give them as illus-
trative of the subjects and tenor of her conversation at this time. She had
a great deal to say about Dr. Webster, their old family physician, and about
all the persons with whom she was most familiar, while a young child, but
whom she had not seen, and whose names she has rarely heard mentioned
for eight or nine years. She says but little of recent events, with a single
exception. At different times during her sickness she has been visited by
two gentlemen who have attempted to produce in her that state of the sys-
tem, constituting artificial somnambulism. She has also been examined and
prescribed for by two other individuals — females — themselves somnambu-
lists. A fifth person, a physician — has a few times seen her, and once pre-
scribed for her, cowhage. These five individuals are frequent subjects of
her remarks. She gives them all the title of doctor f and whenever she
speaks of them her whole manner becomes animated and even boisterous.

Bartlett’s Case of Chronic Cerebral Affection, 55

She laughs with great glee, claps her hands, directs her eyes towards the
ceiling, and talks in a loud tone of voice. She frequently exclaims, “ There
they are! O, how mad they will he! O, how silly they look! They can't get
in! I have locked them out!" And so on. She always speaks of her phy-
sician with great kindness and confidence. Every thing that is right she
attributes to him; every thing that is wrong to some one else. Speaking to
some one of her old associates in England, she said, Give the doctor a
good bed, it's no matter where I sleep."

During this state, the sense of pain in the head still seems to be present.
In her most violent motions, she often clasps her head with both hands; and,
for a moment, buries it in the pillows or in the bed. This afternoon, during
my visit, she said, “ Jane, don't let mother know how my head aches!" fre-
quently repeating, also, “ O this poor head! O my poor head!" At these
times, she pays no regard to things or persons about her. Once, when the
paroxysm went off, and she had returned to her natural state, she said,
“ Where have I been?" She is then exhausted, and feels sore. She retains
no recollection of the occurrences of the paroxysm.

July \Qth. — Last Thursday or Friday, the paroxysm commenced about
fifteen minutes past ten o’clock in the evening, and continued till towards
night, the next day. Her first question, on the return of natural conscious-
ness, was, “ Has it struck eleven?" Another paroxysm commenced on Satur-
day evening, and with some very brief, fugitive glimpses of her natural state,
continued through Sunday, and was still present at my visit, this forenoon,
Monday. All through yesterday, she talked as though the day was Satur-
day— spoke frequently about the children going to Church to-morrow," &c.
This morning she still had the same consciousness, in regard to time, although,
in answer to a question, she said to-day was Monday, because her father had
told her so. The state of the patient’s mind, during this preternatural con-
dition, has changed, in one respect, since yesterday. She is now perfectly
conscious of surrounding things — recognuses persons about hier— talks with
them — answers questions, <fec.; but the tone of her voice is still bad, and her
manner violent, animated and wild. Her eyes are open, and the balls not
rolled up in the sockets, excepting at intervals, and then only for a moment.
At times, during these periods, she amuses herself with her books and letters;
then she will call for her slate and pencil. During my visit to-day, she sud-
denly exclaimed, “/ know how to cypher! I know how to cypher! I can tell
how many minutes there are in a day! I can tell how many seconds there are
in a day!" She had neither slate nor pencil; but she turned her face down-
ward towards the bed, smoothed the sheet with her right hand, and, for a
few seconds, moved her fingers rapidly, as though she was occupied with a
pencil in doing a sum. She then gave correctly the number of minutes and
of seconds contained in twenty-four hours. Whether she gave these results
from memory, or whether she actually went through the calculations at the
time, I have no means of knowing. There were manifested, at different

56 Bartlett’s Case of Chronic Cerebral Affection,

limes, various other phenomena, which seemed to show extraordinary quick-
ness and acuteness of some of the senses. The transitions from one state to
another are becoming more frequent, and they are always instantaneous; in
the twinkling of an eye, quick as a flash of lightning, the tone of her voice,
the expression of her countenance, and her whole aspect and manner are
changed. She has nearly ceased talking of old affairs. The physical con-
dition of the patient remains essentially the same.

August 2Qth. — For the last month, she has, in some respects, been slowly
improving. She is still subject to the two states, which have already been
described. Her loud and violent manner has, however, almost wholly ceased.
These periods occur now, most frequently, in the night. For the most part,
she is, during the day, quiet, and has her mind fully and perfectly. She has
only a confused and very indistinct remembrance of the occurrences of July.
She remembers imperfectly some things, when they are told to her, but says
they all seem like dreams. She is able to sit up during most of the day.
She has a few times rode and walked out of doors. Within a few days, she
has had her menses, after an interval of three months. Her appetite is
almost entirely wanting, and she takes but a very small quantity of food.
The headache still continues, although she says it is not quite so bad.

October \Sth. — After August 20th, I was some weeks absent from home,
and did not see the patient. Nearly two months ago, she was carried to the
sea coast, where she remained only ten days. Ever since that time, she has
been in a very bad state. The two conditions still continue, and she is con-
stantly and frequently passing from one to the other. Some days, during her
crazy turns, as her mother calls them, she is noisy, tossing herself about, and
screaming. When these are absent, she is, as she always has been, still,
quiet, perfectly self-possessed, conscious of her situation, with a sad, dis-
tressed expression of countenance. For some time past, there has been ex-
quisite tenderness of the scalp. She starts, shudders, and screams at the
slightest touch. She avoids touching her head with her own hands. In the
severest paroxysms of pain, she clenches her hands, grates her teeth, and
literally shudders with suffering; but she does not put her hands to her head.
The headache is just as bad as it ever was; there is no remission, no miti-
gation of its intolerable severity. During the preternatural state, she talks
for hours together about her head, and about not letting anybody, and espe-
cially her mother, know how bad the pain is. Within a few days, during
my visits, I have heard her say — “ O what pain! what pain! I don’t want
mother to know — I never told anybody; no, and I never shall — my head is on
fire — my eyes are on fire — 1 can’t hide it much longer — I try to hide it from
my poor mother — I try to get up and he cheerful; hut O ivhat agony, agony,
agony! — Nobody knows; 1 shall never tell anybody. ’’’’ At these times, she
seems to be sensible to surrounding objects; but she very rarely takes notice
of any thing which is addressed directly to herself.

Bartlett’s Case of Chronic Cerebral Jiffection, 57

November 12th. — The patient is still in nearly the same state. There is no
relief to the headache. She said to me to-day, it has never been so bad as
it has for a few days. She says that she does not mind the external soreness
so much as she did, because the headache is so severe. I found her to-day
sitting up, in a rocking-chair, with a book in her hand. She had read be-
tween sixty and seventy pages. She said she could remember most of her
reading, as well as she ever could. Her cheeks were of a bright rosy red.
She said that her head felt hot; but that her whole body, inside and out, was
chilly. She has often complained of this. She takes but very little food.
She has pretty often gone forty-eight hours without taking a particle of food
or drink. Her mother says that she does not take, on an average, for weeks
together, more than a single cracker daily. She drinks lemonade and coffee.
Her pulse is about 80, feeble and soft. Her bowels are regular, and her
tongue clean. The numbness of the feet is almost constant. For the last
week, she has been, most of the time, conscious, and free from her wild
paroxysms.

January 2Qth, 1839.— No essential change has taken place since the last
entry. For a few weeks past, her talking has consisted mostly of expres-
sions of resignation, religious hope in the future, recitations of hymns, and
quotations from scripture. While I was sitting by her bed, a week ago, she
said — “ My suffering increases every day. O, mother, don’t trouble your-
self about me. When 1 am gone, you have plenty more. No creature can
tell the suffering that I have had for three years and three months — O no
creature can tell. I will soon go to my Heavenly home, where the wicked
cease from troubling and the weary are at rest. Heaven will repay all that
I have suffered here. As St. Paul says — When this earthly tabernacle is
dissolved, I have a house not made with hands, eternal in the Heavens.” —
She moans almost constantly; and at times shrieks with the pain. She suf-
fers, also, exceedingly from the exquisite sensibility of the scalp. To-day,
her father, while engaged in writing the names of his children in the Bible,
miscalled the date of the birth of one of them. He was immediately cor-
rected by the patient. After my visit, she said, “ I suppose they won’t be-
lieve it, but I remember distinctly when John w^as born.” She was then
seventeen months old. The quantity of her food is still exceedingly small.
More than once, she has passed forty eight hours without taking a particle of
solid nutriment, or a drop of drink. Since November, 1838, she has had
three very violent attacks of the convulsive cough. They did not yield to
the Prussic acid, but were removed in a few days by free doses of the extract
of belladonna. The distinct mental states still continue, with their quick
and frequent transitions from one to the other. Most of the tinie, she is in
the preternatural state, or, as her mother says, she is lost.

February 20i5^.— For the last three weeks, the patient has been slowly
improving. The headache is less violent, but not removed; and there is less

58 Wyman’s Case of Cancerous Ulceration of the (Esophagus.

tenderness of the scalp. She has been constantly conscious. She gets some
sleep nearly every night, and has been able, for the last fortnight, to sit up
several hours, nearly every day. There is less flushing of the face, and less
coldness of the hands and feet. The sense of heat in the head still continues,
and although she takes food rather more freely, it is not because she has any
appetite for it. I asked her, a few days ago, if she was confident about her
recollection of the time when her brother John was born. She smiled, and
answered, that she remembered it as well as though it happened yesterday.
She said that she had no remembrance of this event before her present sick-
juess. Most of the events of her sickness, except in relation to the lapse of
time, are very indistinctly remembered.

Lowell, Mass., 25/A February, 1839.

Art. IV. Case of Cancerous Ulceration of the (Esophagus opening into

the Trachea. By Morrill Wyman, M.D., Cambridge, Mass.

R. -B. came under my observation, July 10th, 1838. Patient tall, large
frame, much emaciated; aetat. 70. Reports he has not been in good health
for eight or ten years. During several months past, has lost flesh and
strength. Three months since, while at dinner, first perceived difficulty in
deglutition. The morsel, a piece of meat, was arrested in the oesophagus,
and he was obliged to return it to the mouth by hawking. From that time
to the present, deglutition has become more and more difficult, forbidding
the use of any other than liquid or soft solid food. He suffers no pain in
the oesophagus, except an occasional burning sensation. Feels assured that
his food always passes down to the same point, midway of the sternum, be-
fore it meets with any obstruction, or is returned to the mouth. When it is
returned, it is not by any exertion on the part of the patient, but by an in-
verted action of the oesophagus.

OEsophagus examined by means of an ivory ball-probang, one half an inch
in diameter. Instrument passed readily to seat of stricture, ten or twelve
inches from the teeth, but there stopped suddenly without being in the least
engaged in it. A similar ball, three-eighths inch in diameter, became slightly
engaged, but with moderate force would not pass; a third, one-fourth inch
in diameter, passed readily into the stomach. Stricture about eight inches
from pharynx, one and a half inches in length; passage small and apparently
rough from projecting masses along its sides.

July 22(1. — Called to patient, who informs me he was able to swallow as
asual, till thirty -six hours ago, since that time has swallowed no food whatever;

Wyman’s Case of Cancerous Ulceration of the (Esophagus, 59

is faint and exhausted. Says he is very hungry; lakes food frequently, but
in two or three minutes it returns again to his mouth — “ shall surely starve,
if not soon relieved.” The smallest ball-probang passed through stricture;
still patient couhl neither eat nor drink. After some difficulty, a very small
stomach tube was introduced, and a half pint of milk porridge thrown in by
means of a pump; in four hours, a pint more of the liquid was administered
in the same way.

23d. — Reports he was much revived by food; in evening was able t©
swallow again. This morning, has taken breakfast (ginger-bread made soft
in tea,) with much more ease than usual. At noon, ventured upon a small
piece of pork, w'hich also passed. Still very weak.

30th. — Since last date, deglutition has improved gradually; none of his
ordinary food has been returned, but is careful that it be either soft or in very
small pieces. Strength increasing.

During latter part of summer and fall, patient has been employed about
his house as usual, doing such things as his strength would allow. About
once in ten days, has had ball-probang, one-fourth inch in diameter, passed
through stricture. This has never been done, however, unless he has been
obliged to submit to it by a fear of complete closure of the oesophagus, and
consequent starvation. At each time the difficulty in passing the probang
was increased, not only by the narrowed passage, but also by the difficulty
experienced in finding it. The instrument required a certain direction, or it
w^ould slip into a little excavation at the side of the true passage, through
which there was, apparently, no opening into the oesophagus below the
stricture.

October 17 th. — On withdrawing the probang, it was found besmeared
with a brownish coloured, slimy, very fetid matter. During two or three
days following, skin hot and dry; tongue coated; pulse accelerated. These
symptoms soon passed off, and he recovered his usual state of health, with
an ease of deglutition greater than he had enjoyed since the July previous.

This state continued till the last week in December, but with no improve-
ment in strength or flesh. He now began to have cough, with some dys-
pnoea. The cough was increased on taking food, which he said produced
“ a terrible burning” behind the upper part of sternum. Food frequently
rejected, even when liquid, after remaining a few minutes in the oesophagus.
During the following week, became more sick. Thirsty; skin hot and dry.
Pulse, 108; tongue coated; dry. Weaker, and, if possible, more emaciated
than before.

January 9th. — Took to his bed on account of extreme debility. Cough in-
creased; expectoration principally mucus, with some of the liquid he has
attempted to swallow. Chest resonant on percussion; coarse mucous rales
in both backs; sound of respiration distinct. Pulse, 110, small. Craves
cold water only; thirst great. Two liquid dejections daily, not large. From
this date, cough more distressing. Difficulty of deglutition not increased,

60 Wyman’s Case of Cancerous Ulceration of the (Esophagus.

although burning sensation behind sternum is still complained of. The
pulse became more rapid till the evening of the 12th, when it was at 120
per minute. During the night of the 12th, extremely restless, and on the
morning following, after being turned in bed by his attendant, immediately
expired.

The body was examined thirty hours after death, in the presence of my
father. Dr. Rufus Wyman, and several other medical gentlemen. Exter-
nally, body extremely emaciated; muscles very distinct; chest large; abdo-
men very much sunken. Tongue, pharynx, oesophagus, stomach, and the
contents of the chest removed together. Pharynx appeared healthy through-
out, as did the tongue. Epiglottis large, healthy. Nothing abnormal dis-
covered in removing the oesophagus until its connections were destroyed
as far as the fourth dorsal vertebra, where such strong adhesions were
found between it and the periosteum, covering that bone, that they
could be separated by the knife only; adhesions hard and grating under
the edge of this instrument. (Esophagus of the usual size at its junc-
tion with the pharynx: below this, larger than usual till near the level
of the fourth dorsal vertebra, where its sides became thickened and calibre
diminished by a rough tuberculated surface to the diameter of one-eighth of
an inch. This contracted portion extended about two inches of the length
of the canal. This part in a state of ulceration with fetid matter adherent.
Two ulcerations were observed deeper than the others, and, on gently in-
serting a probe into one of them, it passed freely into the trachea. The
trachea and bronchi being then laid open, another ulceration admitting a full
sized dressing probe was seen in the posterior membranous part of the
trachea exactly at its bifurcation. This, too, communicated with the cbso-
phagus at its thickened, ulcerated part. The trachea and bronchi near the
openings, showed evident marks of inflammation; mucous membrane red,
roughened, and in some parts a purulent secretion upon its surface. On the
tracheal side, the openings were smooth, with the edges thin and well de-
fined; on the opposite side rough, with ulcerations leading directly down to
them. Some adhesions of long standing existed between the lungs and
pleura costalis, but otherwise these organs were remarkably healthy. Sto-
mach~carefully examined at its cardiac and pyloric orifices, but no thick-
ening or schirrous appearance observed.

Cambridge, Mass., February, 1839.

Adam on Remedial Powers of Persesquinitrate of Iron,

Art. V. On the Remedial Powers of the Persesquinitrate of Iron. By
T. C. Adam, M. D., of Lenawee county, Michigan.

For upwards of five years we have been in the habit of prescribing,
almost daily, the liquor ferri persesquinitratis, a remedial agent first dis-
covered and introduced to notice, we believe, by Wm. Kerr, Esq.; though
Dr. Graves, in a clinical lecture, quoted in No. XXXV. of this Journal,
ascribes this merit to Dr. Christison, of Edinburgh. We have derived
from its use very remarkable assistance in the treatment of several diseases,
especially diarrhoea, and other affections of mucous membranes accompanied
by discharges; and as its virtues seem not to be so generally known in this
country, as they deserve to be, we have been induced to lay before our
brethren a few observations illustrative of its value as a therapeutic agent.

The formula for the preparation of this remedy, as given by Mr. Kerr,
will be found in the No. of this Journal for May, 1832, p. 235.

Our first trials of this remedy were in cases of diarrhoea^ and from its
employment we have derived highly beneficial results. We must not be
misunderstood to mean that this astringent is applicable to every case of
diarrhoea, or that it has been found indiscriminately useful. We have not
thought proper to administer it in every variety of this complaint; but of
its beneficial effects in such cases as the following, we can speak with much
confidence.

In January, 1832, a child of six months of age became our patient, on
account of a diarrhoea, nearly habitual, but aggravated by dent/ticn. Im-
mediate relief was obtained by meads of a free incision through the gums,
down to the tooth or teeth. The fretfulness ceased, and the diarrhoea sub-
sided to its usual degree. Two drops of the nitrate vere then ordered
three times a day, and to be continued for at least ten days after the cessa-
tion of the diarrhoea. The effects of this treatment were a cessation of the
habitual diarrhoea for at least eighteen months, ^fld an improvement in rud-
diness of complexion, and in temper or feeling^ of comfort.

In April, 1832, a lady applied for advice, probably in consequence of the
threatened invasion of cholera. Her Vowels were very readily moved,
generally tender or uneasy; she was languid and weak, pale and emaciated,
and was much troubled with cold ffet and profuse perspirations. She had
been subject to diarrhoea from tb^ slightest causes for several years. Intelli-
gence of an unpleasant nature would almost invariably produce it. For her
I ordered frictions with salt *vater to the surface, and the nitrate, in doses of
15 to 25 drops, four time^ a day. After using the remedy a few days, this
lady commonly improved; but from giving up its use too soon, the relief was
not of long continuance.

We have generally ordered the medicine to be continued for at least ten days

No. XL VII.— May, 1839. 6

62 Adam on Remedial Powers of Persesquinitrate of Iron,

after the disease disappears; and have continued its use as long as four
months after every threatening of diarrhoea was gone. The diarrhoea
never returned for several months, if the medicine was faithfully taken for
ten days or more; hut, as in the case of this lady, we have had relapses
in those who neglected the usual order so soon as amendment took
place. This lady’s case closely resembles that alluded to by Dr. Graves
in No. XXXV". of this Journal. We may remark in passing, that Dr.
Graves prescribes the nitrate in much smaller doses than we have been ac-
customed to do. We prescribe ten drops at a dose, two, three, or four times
a day, frequently twenty-five; whereas Dr. Graves gives seven, gradually
increased to fifteen drops in the course of the day; and we think we have
obtained a more rapid amendment, from the larger dose.

A lady, about 30 years of age, had had diarrhoea for ten months pre-
viously to her applying to me. It commenced as soon as she got up in the
morning, and continued all forenoon; in the afternoon it subsided almost en-
tirely. It was accompanied with but little pain; but there was considera-
ble thirst. During the ten months she had tried a variety of proposed remedies
in vain. She has never been free from her complaint except for about two
weeks, after having taken some purgative pills, which operated very pow-
erfully. In constitution and symptoms, this case was exactly parallel with
those referred to by Dr. Graves^ in the XXX Vth No. of this Journal. She
took ten drops of the liq. persequinitr. ferri, gradually increased to twenty
drops, three times a day. In four days she was nearly quite free from the
diarrhma; and in two weeks felt stronger and in better health than for ten
months previously. For about a year, as long as we knew her history, she
had no return, of diarrhcea, or bad health.

A gentleman', about 30 years of age, had recently moved to Michigan,
when he applied to me on account of diarrhoea, accompanied with conside-
rable uneasiness and griping pains. He attributed these complaints to the
changes he had been obfiged to make in his diet, especially to eating more
pork than usual with him, ^jid partly to the water he had to drink. I could
ascertain no other causes in b^eration, and thought his own etiological theory
probably the true one. To less^ the irritability of the mucous membrane,
and at the same time restrain theN^ischarges, I could think of no medicine
more likely to be effectual, than th^^nitrate of iron. Fifteen drops were
taken three times a day in water, and dtv^the third day he reported himself
much relieved from the griping pains and \neasiness in abdomen. By con-
tinuing the use of this remedy for not more\han ten days, this gentleman
obtained complete relief from his “new coum|*y” complaints, which had
existed upwards of six weeks before the nitrate wfc^ prescribed. From the
efiects of the remedy in this case, and from some sf^^ilar observations in
other cases, we were inclined to believe that this nitrate, like some other
metallic nitrates, had the property of subduing morbid sensibility of the

Adam on Remedial Powers of Persesqiiinitrate of Iron. 63

organic nerves. In the paper of Dr. Kerr, will be found a case remarkably
confirmatory of this theory.

Since we commenced the use of the nitrate of iron, there has seldom
been any long interval between our cases of children who were habitually
subject to oft-recurring attacks of diarrhoea, and who occasionally had attacks
of what mothers call worm fever — infantile remittent. In such cases diar-
rhoea not unfrequently alternates with constipation. It is seldom such cases
are put under medical treatment, except when the remittent fever or the
diarrhoea is more than usually severe. We have generally had children of
this description put under our charge when they were labouring under fever.
With doses of calomel and rhubarb, followed by oil in the morning, repeat-
ed every second night, and conjoined with a bland, easily-digested diet, and
with attention to ablution, quietude, and Warm clothing, vve have usually
succeeded in alleviating or curing the fever. We have, then, in a majority
of cases, recommended that the child should, for some w^eeks, have a bland
nutritious diet, consisting chiefly of well-boiled farinaceous articles, and
make use of the nitrate of iron regularly. In several instances we have
failed to procure a steady employment of this medicine for a sufficient
length of time; in some, again, the parents have continued it, of their own
accord, for upwards of two months; and in all the cases in which it was
regularly administered for a period of three weeks or more, we do not know
that such children were again attacked with fits of diarrhcea, or suffered
from infantile fever. Of several we can affirm confidently, that they were
altered subjects; formerly pale, exsanguine, peevish, delicate, and requiring
much anxious attention, they have become hale and fresh-coloured, strong,
playful, and easily taken care of.

Sucii are the varieties of diarrhoea for which we have most frequently
prescribed the liq. persesquinitr. ferri. They are all of a chronic nature,
and the temperament of both the younger and the adult patients has had
a large admixture of the nervous. This wq incline to attribute to the irri-
table condition of the mucous membrane of the intestinal tube, and to the
debilitating effects of frequent diarrhoea. Numerous cases, similar to those
given, might be produced from our case-book; but our purpose is, solely to
indicate clearly the kind of cases in which we have employed this medicine
most frequently, and in which we have found it without a rival. For this
purpose we have given, we hope, sufficient narration, and avoided “ vain re-
petitions.” We will now add a few explanatory observations.

The dose which we employ in adult cases is, as we have already inci-
dentally remarked, much larger than that which Dr. Graves is reported to
employ. We seldom order less than fifteen drops at the commencement;
and after a few days of employment of the remedy we increase the quan-
tity to twenty, twenty-five, and thirty drops at a dose. For children we
proportion the dose according to the age. We have only in one case that
we recollect of, that of a Mrs. J. Dunlop, had occasion to reduce the quan-

64 Adam on Remedial Powers of Persesquinitrate of Iron,

tity. In this case, which, by the bye, was one of recent, not habitual diar-
rhoea, the usual dose did not produce any alleviation of the symptoms, but
seemed rather to increase the griping pains; we, therefore, reduced the
quantity to seven drops, and in less than twenty-four hours, the amendment
was very marked. We have administered, and we have taken as much as
a hundred drops; but, lately, where the usual quantity does not produce re-
lief in two or three days, we prefer adding a little laudanum, or employing
some other auxiliary, to the employment of more than thirty-five drops. At
the same time, we have never experienced any bad effects from so large
a dose as even a small teaspoonful, which we have frequently known to
be taken three and four times a day.

The time during which the nitrate will keep good, that is, clear and trans-
parent, varies considerably. Dr. Graves says about a week — some of my
acquaintances and correspondents say three and four weeks, while I myself
have never had any become turbid in less than five or six weeks, and gene-
rally I have it quite transparent for two months or upwards. I have also
used it turbid without any sensible diminution of its astringent effects. Mr.
Kerr, however, thinks that when it has become turbid, it is not so powerful.
It is only in a few instances that we have employed it after this change.

In cases such as we have above described — cases of habitual diarrhoea,
from birth perhaps, in children, and in cases in which there seems to exist
an excess of irritability in the digestive tube — we know of no medicine
which produces a more beneficial, immediate effect; and certainly, in its
power of preventing similar attacks in future, this remedy is without any rival,
so far as our experience extends. In cases of children, we have found its
long-continued employment produce the most satisfactory results.

We have endeavoured to guard against any misconception of our ideas as
to the cases or morbid condition to which our remedy is particularly appli-
cable. We meet with chronic diarrhoea in two forms — persistent and what
may be called intercurrent. The former is generally the consequence of a
severe acute attack; by the latter, we mean to designate such cases of this
disease as consist in a tendency or predisposition, or in the frequent occur-
rence of slight attacks of an acute kind, the usual state being more or less
normal, or rather inclination to constipation. In the majority of cases of
both kinds, the proximate cause, as the pathological condition has been
called, undoubtedly consists, not so much in the application of foreign irri-
tating matters, or on faecal accumulations or morbid secretions, or on an
undefined debility or relaxation of the mucous membrane, or on congestion
or inflammation, so much as on an excess in the sensibility of the organic*
nerves which supply the digestive tube. It is not for chronic diarrhoea— b,
name for a symptom not a specific condition, that we prescribe this chaly-
beate astringent and sedative; but when, by investigation, we have satisfied
ourselves that the diarrhma is dependent on the above named condition, we

Adam on Remedial Powers of Persesquinitrate of Iron* 65

then employ this remedy in preference to opiates, or any other anti-diarrhoeal
medicaments.

Having thus laboured lo indicate, with precision, those forms of disease
in which we have derived from the use of the liq* ‘persesquinitr* ferri the
most satisfactory and beneficial results, we will now briefly notice a few ad-
ditional forms of disease, in which we can speak favourably of its reme-
dial effects, though not with the confidence we feel as to our previous obser-
vations.

In Leucorrhoea, we have employed the nitrate of iron with excellent suc-
cess. But to procure benefit, we are careful in the selection of proper
cases. These we think are such as seem chiefly dependent on a laxity of
fibre, or on an over-secretion without inflammatory action. The persons in
whom we meet with this kind of leucorrhoea, are generally pale, exsanguine,
feeble, languid. We would not administer the nitrate where there was rea-
son to suspect any disease of the uterus. But in the former kind of cases,
we have employed it very successfully, using it internally, generally, and
always topically, in injection. We add to four ounces of water such a quan-
tity of the nitrate of iron as will produce in the vagina a gentle degree of
heat or smarting. The internal use is prescribed where it is probable that
the system by this means may be so roborated as to aid in the cure of the
local disease. Almost all the preparations of iron are useful in such cases,
and we think this not inferior to any in this respect.

In several cases of Menorrhagia, we have found this astringent and tonic
of much service. We think it may be preferred, in cases accompanied
with anemia, debility, and relaxed fibre, to any astringent in common use.
We know of none equal, save a mixture, in equal proportions, of the sul-
phates of alumina and iron.

We have made trial of the remedial power of this medicine in such
cases of almost all the diseases in which astringents are usually prescribed
as we thought the most appropriate. We do not know of any case in which
the nitrate enjoys a marked superiority to the common astringents; but judg-
ing from our experience, we presume it will be found a convenient and useful
addition to the list of such remedies.

Dr. M. A. Patterson, of Tecumseh, informs me that he has found the
nitrate of much use in the treatment of aphthous sores, or what is vulgarly
called “ canker.” Our experience, though small, confirms the utility of this
application of the medicine.

A gentleman, in whose house a bottle of this remedy was at a time when
he had the toothache, applied a few drops sud sponte, and obtained relief.
May the nitrate of iron not possess a sedative or anodyne effect like the ni-
trates of silver, bismuth, &c.?

In fine, it may be mentioned as no small recommendation of the prepa-
ration, that it is cheap and easily procurable, and as each practitioner can
prepare his own, it may be depended upon as uniform and unadulterated in

Marcy’s Case of Partial Sweating,

any important emergency. Those who have felt the deficiency, in purity
and uniformity, of many of our remedial agents, will account this as not the
smallest of its recommendatory qualities.

Art. VI. Remarkable Case of Partial Sweating. By Samuel S. Marcy,
M. D., of Cold Spring, N. J.

The subject of the following case, John Fallopius, setat. 45, of san-
guine temperament and of strictly temperate habits, has never suflfered a day’s
sickness, with the exception of the ague and fever, and is in every respect
a healthy, athletic man. From the year 1823 to ’30, he was attacked with
every variety of ague and fever, from the slightest chill perceptible, to the
most violent ague possible, embracing the tertian, quartan, quotidian, and
double quotidian type; and much of the time accompanied with excessive
night sweats, equal to a Thompsonian sweat. Now, and for the last six years,
has been free from that or any other disease, but is subject to profuse per-
spiration on taking much exercise, perspiration greatly disproportionate to
the exercise or labour; while in a recumbent posture, the perspiration is con-
fined to the upper half of the body and extremities; the opposite, or under
side perfectly void of any moisture; temperature natural; change his posi-
tion to the opposite side, and in a short time perspiration subsides on the
side he is laying upon, and commences on the upper side again, and so on
as often as he chooses to change his position. A line of perspiration would
be correctly marked by a line drawn from the centre of the frontal bone to
the pubes, including the extremities. The patient has often amused him-
self and friends, by noticing his one-sided sweating propensity on changing
his position from side to side. While in an erect position, the perspiration
was uniformly diffused over the whole surface. During the past extremely
warm summer, his eccentric perspirability continues even in the erect posi-
tion, and he continues to amuse his friends by exhibiting one side of the
face covered with pearly drops of perspiration, while the opposite side is en-
tirely free from any moisture. Since it showed itself in the erect position,
it is confined to the left side exclusively, and so continues.

I submit the facts to the profession as I have often witnessed them, con-
fident that there is no deception in the case, leaving them to give the why
and wherefore. I cannot give a reason that will satisfy myself.

Cold Spring, Cape May, Aug. I5th, 1837.

Porter’s Case of Epilepsy,

Art. VII. Case of Epilepsy, By Charles A. Porter, M.D., of New

York.

In the number of this Journal for November, 1838, there are given the
results of M. E. Esquirol, in the treatment, cure, &c. of Epilepsy. Our expe-
rience so well accords with those results, that we are induced to report the
following case recently treated.

February 7th, 1838. — I was requested to visit Miss D. of this city, aetat.
17, who has been subject to fits for three years: produced at first by anx-
iety of mind. In her infancy she was sickly. But since she was attacked
by these fits, her health has been excellent. There is considerable regu-
larity in their recurrence every fifth day. Her mother remarks that such
is particularly the case when there is a new moon. After this, and espe-
cially at the full of the moon, there is an interval of seven and more days.
On a careful examination we find heat of head slightly abnormal: extremi-
ties cool. Temperament nervo-lymphatic. Menses regular. At their com-
mencement and cessation, she has a fit.

Appetite always good, craving fat, hearty food; free from pain in the
epigastric region, and indeed over the entire abdomen. She has been in-
dulged in her desire for food. No regard, as I am informed, has been
paid to diet by her medical attendants, of whom there have been several;
one a homoeopath. Pulse so small, that it is with difficulty it can be felt,
and preternaturally frequent. The tongue denotes gastric irritation: pa-
pilla red, shining through a white fur. I directed a mild, unirritating diet,
as mush and milk; abstinence from tea and coffee; the frequent and repeated
use of revulsives, as foot baths made stimulating with cayenne pepper,
mustard and nitro-muriatic acid; a large poultice of mustard and Indian
meal over the bowels; and a similar poultice over the spine, as there is
tenderness about upper dorsal region, and after that apply a tartar eme-
tic plaster to the same spot. By this plan of treatment, she escaped her
fits just one month, until March 7th, when she had a fit, which was very
light.

This was followed in five days, March 12th, by another occurring in
the morning, which was severe, and lasted nine minutes. There was a
loss of consciousness, which remained for two minutes before the patienl;
fell. 4fter the fit she complains only of dulness in the anterior portion
of the head. Pediluvium for the evening, made stimulating with mustard.

March \^th. — Patient feels well in every respect. Dorsal spinal ten-
derness present, but in an inferior degree. Bowels rather confined; direct-
ed a pill of mass, hydrarg. grs. v, and sulph. magnesia 5ij following morn-
ing. Our patient, it should be mentioned, is operated upon by very little
medicine.

15^/i. — Commenced giving tincture of stramonium. Directed two

Porter’s Case of Epilepsy,

doses that day, sixty drops each. We were careful to obtain the seeds
of a gentleman who collected them at the proper season, and had the tinc-
ture made under our own direction with ^iv seeds to alcohol Oj. Sixty
drops were repeated three times a day until March 18th, when I discovered
sensible efiects from the medicine. Pupils much dilated, with double vision,
and stupid look, similar to a person with the first effects of inebriation.
Directed medicine discontinued for that day.

IQth. — Find that the dilatation of pupils is removed, and patient
can discern objects naturally. Directed the tincture continued in thirty
drop doses, three times a day: a pill of mass, hydrarg. aloes and rhubarb
at night, and a pediluvium with a large cupful of mustard. Continue to
irritate the spine with tart, antimon. unguent.

2^th. — The tincture was taken twice yesterday. The pill had no
effect. Repeat the pill at night, and salts in the morning, if requisite.
The pulse gains more force, and is near the natural standard — 70.

22d. — The pupils are considerably dilated. There is a w'ild appear-
ance of the eye: the patient complaining of imperfection of vision.
Directed medicine to be continued in fifteen drop doses.

23d. — Directed for the evening dose thirty drops.

2Uh — Continue medicine in thirty drop doses.

April Uh. — The stramonium has produced looseness of the bowels; but
pretty constantly since last date, thirty drops have been taken three times
a day. She is at present menstruating. I have directed a pill three times
a day, containing oxyd-rubr-ferri grs. ij, extract conium-maculatum, grs. ss.
And to an ounce of the tincture, I have added sulph. morphia grs. ss.

bth, — Takes gtt. xv of tinct. for a dose.

8<A. — Takes pills four a day.

The pills and the tinct. are regularly continued until May 10th. Nine
in the evening, had a fit of short duration. Two days previous she com-
menced her menstrual period. This was very immoderate, her mother
comparing it to one who had miscarried. Just prior to the fit, there was a
great flow. After the fit they ceased entirely. It is proper to remark here
that the patient had felt so well, and continued free of the fits for so long a
period, that she had not observed her usual regularity in taking the medi-
cine. Besides, on the day previous to the fit, she had taken an unusually
long walk.

Mayllth, — I have directed the tinct. in doses of 40 drops three times a day
with tinct. opii gtt. xv in each dose, as there is a great tendency in the stra-
monium to run off by the bowels.

21tJi. — Had a fit at mid-day. She had taken gtt. 60 that morning,
and gtt. 45 just prior to having the fit. She felt badly in the morning, and
had eaten heartily of fried eels, contrary to all directions.

2Sth. — Have rigidly enforced a plain diet of mush and milk: apply
all over the abdomen equal parts ol. terebinth, and ol. oliv.: pediluvia with

Hulse on the Bite of a Spider.

mustard, a plaster of extract hemlock, camphor and opium to spine — gtt. 60
of tinct. for morning dose, and continued so as to keep the pupils constantly
dilated. The bowels now costive; this to be remedied by a pill of mass,
hydrarg. aloe and pulv. rheum.

June 28th, — Had a fit, and another five days after.

July ISth. — Directed the following R; 01. terebinth. 5ss: Pulv. sacc. alb.
5ij: Puiv. gum Arab, aa: Aqua destill, ^iv. Tablespoonful three times a
day.

nth. — Had a fit — the menses in large quantity, amounting almost to a
flooding.

23d. — Had a fit. The tongue denoting gastric derangement, we have
discontinued the ol. tereb. mixture, and with our consent, the patient has
gone for a time to reside on the Brooklyn heights, for the benefit of
purer air-r— all medicine discontinued. Diet to be observed, and take warm
salt water baths, (recently established by Mr. Gray of Brooklyn.)

Remarhs, — First. On stricter inquiry, we are led to believe that although
this young lady has been subject to fits in their open, undisguised form, for
three years, she has been predisposed to them from birth — for, in her
earliest infancy, she had an attack — and had several of what are vaguely
termed “ inward fits.” When congenital and hereditary, says Esquirol, it is
never cured.

Secondly. We were induced to consider the fits depending on the concfition
of the menstrual discharge, and directed our treatment accordingly. We
^cceeded with act. plumbi grs. ij and opii grs. ss, frequently repeated, in
moderating the discharge, but not in preventing the fits.

Thirdly. We are led to agree with Esquirol, not from this solitary ease;
for, during two years residence in Philadelphia Alms-house Hospital, there
were many, very many cases, under every variety of treatment, not except-
ing even animal magnetism; and we regret to add, with no more beneficial
results. The disease is a truly deplorable one; and thrice fortunate would
he be who can point us to a certain remedy, even in a small number of
cases.

280 Broadway y January ^ 1839.

Art. VIII. Bite of a Spider on the Gians Penis y followed by violent
symptoms — recovery. By Isaac Hulse, M.D., U. S. N. Fleet Surgeon,
W. I. Squadron. i

On the 7th of August last, Mr. Q. of this place, while in the privy, per-
ceived himself to be stung by a spider on the glans penis. The pain, which
was not great at the moment, continued to increase till 1 p. m., an hour

Hulse on the Bite of a Spider,

after the accident, when it had become extreme, and I was called to see the
patient. 1 found him lying upon a cot, and writhing under the most acute
suffering. The place where the sting was made, showed no marks of irrita-
tion nor swelling. I however applied to it a strong solution of carbonat. po-
tass, which I happened to have about me, and ran to the apothecary’s for
medicine. My absence lasted but a few minutes, and on my return, I found
him vomiting with great violence, and complaining of deep-seated pain in the
abdomen, extending up into the chest, and of sensations of choking and suf-
focation. The vessels of the neck and face were greatly distended, and of a
dark hue. 1 opened a vein in the arm and let blood copiously through a
large orifice, and commenced immediately to give aqua ammoniac and lauda-
num in doses of a teaspoonful of each every ten minutes, which were ejected
as often from the stomach — pains and spasms along the spine and extremities
now came on, and the agony and anxiety were, if possible, increased; Strong
volatile liniment, tinct. cantharides, and spirits terebinth, were alternately
applied to every part of the body by the patient’s numerous friends who had
assembled round him, and common injections were administered as fre-
quently as they conveniently could be, with a view to open the bowels. The
ammonia and laudanum were assiduously plied and occasionally some tinct.
camphorae, likewise; at the suggestion of Dr. Edwards of the navy who
was called in, the oleum olivarum was freely administered. At 3 p. m. the
paroxysms of pain came on at longer intervals, and the vomiting was less
urgent, but the intensity of the pain when present, was undiminished. The
principal medicine relied on, viz. the ammonias and laudanum, were con-
tinued every half hour, and at about 5 o’clock, after the exhibition of fifteen
injections, faecal evacuations were obtained from the bowels. The patient
became much easier in the course of the evening, and was able to retain a
dose of castor oil, which purged him freely; but the pain in the legs con-
tinued through the night, which he passed without sleep.

On the subsequent day, sinapisms were applied to the legs without effect,
and the evening brought little or no mitigation of the pain. Veins were now
opened in both feet, which were placed in warm water, and the blood was
allowed to flow till an impression was made on the pulse. In an hour after
the bleeding, the patient enjoyed perfect ease; he slept well that night, and
on the following day was able to walk about the house. He recovered in
health very speedily.

This gentleman is of dark complexion, short stature, and powerful mus-
cular development.

I saw several spiders in the place where he received the sting. They
were of large size, of a dark brown colour, covered with hairs over the legs
and body.

In this case four ounces of laudanum and an equal quantity of aqua am-
moniae were administered in the space of four hours.

Pensacola, February 2d, 1839,

Logan’s Account of Scarlatina,

Art. IX. A Brief Account of Scarlatina, as it prevailed in the Orphan

House, Charleston, South Carolina, during the months of June and July,

1838. By Geo. Logan, M.D., Physician to the Institution.

The summer commenced with very unsettled weather, the transitions of
temperature were frequent and sudden. On the 2d June, a storm occurred,
accompanied by rain. On the 4th, the heat was oppressive; again on the
7th, Fahrenheit’s thermometer fell to 60°. From this date to the close of the
month, the season was dry and warm; an inflammatory constitution of the
atmosphere resulted.

This was manifested by the character of the prevailing diseases. Catar-
rhal affections were general, and in several instances assumed the form of
pneumonia, requiring the lancet; harassing hooping cough (still lingering in
the institution) was aggravated to a degree which rendered depletion and
blisters necessary. Anodynes could seldom be employed with safety: al-
though the suflferings of the little subjects were protracted, they were all
restored to health before the middle of July.

About the second week in June, the much dreaded scarlatina, which had
afflicted a part of the city for eighteen months previously, first appeared in
this institution. Its distinctive character was strikingly developed. The first
eleven cases were unattended by any malignant symptoms, passing favourably
through the several stages. Swellings of the tonsils, pain and soreness
of the. fauces subsided on the fifth day; desquamation of the eruption took
place on the sixth, and convalescence on the eighth and ninth days.

The subsequent cases were more violent, confirming the observation of
certain distinguished physicians, “ that in large institutions, epidemics in
their progress often acquire a malignancy.” To obviate this as far as
possible, the commissioners with a solicitude and kindness becoming guar-
dians of the “ publics’ children,” consented to appropriate the spacious cha-
pel as an hospital, into which thirteen subjects then under treatment, were
transferred. Disinfecting substances, as chloride of lime, and afterwards
the fumes of vinegar and nitre were introduced into the dormitories and
other apartments.

The most alarming instances were ushered in, with languor, shivering,
pain of the back, tenderness of the epigastrium, vomiting, pyrexia, with
very ardent heat of the chest and body, a phenomenon in scarlet fever, no-
ticed by physicians of antiquity, and among moderns, particularly by Dr.
Currie of Liverpool, who regards this as the hottest of all diseases.

The exacerbations were invariably severe on the second and third nights.
The efflorescence became confluent, with sometimes a tendency to recede
in the morning, or to assume an ash, or purple colour, rather than scarlet,'
great restlessness and delirium were concomitants. Glandular swellings,
anasarca, bydrothorax, and pulmonary affections, attended in many instances;

Logan’s Account of Scarlatina,

enormous imposthumes frequently succeeded, especially where there ex-
isted a strumous diathesis.

In the method of treatment, depletion was resorted to within the first
thirty hours, at the commencement of the high temperature of the body,
this being the favourable moment for vigorous action; calomel, and after-
wards castor oil, or the sulphate of magnesia as febrifuges and anthelmintics,
were generally exhibited; worms being always suspected to increase the
gastric irritation, sometimes an emetic of ipecacuanha had a happy effect
as a diaphoretic, and in accelerating the eruptive stage; cold vinegar was
applied to the head during the height of pyrexia; oleaginous enemas were
useful auxiliaries. Synapisms were beneficial in cases when there was a
tendency to recede, or to assume the “ on the latter occasion,

the internal use of mustard produced a very favourable influence. Detergent
gargles in which a large portion of common salt was dissolved, were usually
employed. Anasarcous swellings, as well as pulmonary affections, and im-
posthumes were frequent attendants, after the mildest as well as the most
alarming forms of the disease, and under every variety of treatment indi-
cated by the symptoms. It might therefore be inferred, that scarlatina is
accompanied by symptomatic fever, with an original determination to the
cutaneous and glandular systems.

In one subject, the oedematous condition of the system, with oppressed
respiration, rendered a recumbent position insupportable; a fatal issue seem-
ed to be rapidly approaching. I ventured to employ bloodletting; the result
exceeded my most sanguine expectations; the benefit was decided and per-
manent, when indeed no professional hope could have been cherished.

Diarrhoea and dysentery were among the sequelae, and our convalescents
were long predisposed to cholera. Upwards of sixty children were under
the influence of this epidemic in the course of eight weeks. Females suf-
fered more than males. The symptoms were most violent in subjects be-
tween five and twelve years; no instance occurred of a second attack in
the same individual; all predisposition seemed to have been obliterated.

One fatal case only have we the misfortune to record, a female in the
eighth year of her age: in this unhappy instance, extreme difficulty was ex-
perienced in administering remedial means; great restlessness and delirium
was observed on the second day; the cicatrix on her arm, for which she was
bled, mortified, as did also a slight bruise produced by a casualty. The whole
surface of the body previous to the disease, exhibited the highest appearance
of malignancy. Hemorrhage from the mouth and nostrils took place two
days antecedent to her death. About fifty inmates of the house (subjects
for the disease,) escaped: whether this exemption was effected by a returning
salubrity of atmosphere in the locality, or to the peculiar action of belladonna,
exhibited at the instance of my son Dr. Thomas M. Logan, in accordance
with the plan of certain eminent European physicians, or to inoculation for
scarlatina, which was also practised as a prophylactic, cannot be deter-
mined; certainly none of the latter subjects were afflicted with the epidemic.

MONOGRAPH.

Art. X. On Pseudormmbranous Inflammation of the Throat. By
E. Geddings, M. D., Professor of Pathological Anatomy and Medical
Jurisprudence in the University of the state of South Carolina.

Synonymes — Pseudo-membranous inflammation of the throat. Angina
Pseudo-memhranacea. Angina tonsillaris membranacea. Angina
Plastica. Angina Diphtheritica^ (Bretonneau.) Angine Couenneuse
(Guersent.) H'dutige Br'dune. Germ.

These several terms have been employed to indicate a peculiar form, or
grade, of inflammation, attacking the mucous membrane of the throat
and adjacent parts, the most conspicuous character of which is, the format
tion of a thin pseudo-membranous pellicle, either continuous or disposed
in patches, and intimately adherent with the surface of the membrane pro-
ducing it. The appellation Diphtherite, or Diphtheritis, (from
membrana^ exuvium,) applied by Bretonneau to this affection, has been
subsequently adopted by many of the French writers, and by some of other
countries. He wished to indicate by it, a specific inflammation of the
mucous membrane of the throat, characterised by the development of a
membranous exudation upon the surface; and besides the proposition re-
lating to its specific character, he attempts to prove, that this affection is
identical with the angina maligna of authors; that croup is only the last
degree of this disease; that angina maligna, or gangrenosa, is not gangre-
nous; and that there is no relation between mortification and the alterations
to which this disease gives rise.*

The close affiriity, if not the absolute identity, between angina membra-
nacea, and angina gangrenosa, has been so fully established by the concur-
rent observations of ancient and modern pathologists, that there can be but
little question about the propriety of considering them as different grades
merely of the same affection. But croup, as it has been generally described
and understood, by most of the writers of the last and the present century,
is a disease so essentially different in most of its leading pathological cha-
racters, that it cannot be properly classed with either of the other affec-
tions. Diphtheritis, when it extends into the air passages, often gives rise
to the formation of a false membrane upon the surface of the mucous mem-
brane lining the larynx, trachea and bronchia; but this condition is widely
different from croup, properly so called; and Bretonneau and his followers
have created great confusion by their attempts to establish their identity.

The pellicular deposite formed upon the surface of the mucous mem-
brane of the throat in the anginose affections, did not escape the observa-
tion 6f the early writers on medicine; but we are certainly indebted to
Bretonneau for a better description of the disease in which it occurs, than
had been given by his predecessors. The affection denominated prunella^

* Traite de la Diphtherite, p. 11. Paris, 1826.

No. XLVII — May, 1839. 7

Monograph

by some of the ancient authors, was probably identical with the diphthe-
ritis of Bretonneau. It is described as a chronic inflammation, spreading
from the root of the tongue to the precordia, characterised by burning pain,
a dark red colour, and the development of a whitish pellicle upon the sur-
face of the inflamed membrane.* The description given by Aretaeus, of
the ulcers of the tonsils, can apply to no other aflTection than the one under
consideration. These, he says, are sometimes mild, and without danger:
aliqua aliena, pestifera, necanlia — pestifera sunt lata, cava, pinguia, quo-
dam concrete humore albo, aut livido, aut nigro sordentia — crustam vero
circumveniunt rubor excellens.f Similar remarks are made by the same
author in other parts of his work, and corresponding descriptions might be
cited from several of the writers of antiquity. The disease seems to have
been of frequent occurrence during the seventeenth century, and was de-
scribed, more or less in detail, by several of the writers of that period. It
often appeared as a destructive epidemic, falling with its greatest force upon
children; and as such was described by Carnevale, at Naples, in 1618;-—
in other situations, and at different periods, by Renatus Moreau, Alaymus,
Francis Nola, Severinus, Wedelius, Cortesius, Zaculus Lusitanus, Ghisi,
Heredia, &c. It appears to have prevailed with frightful ravages in Spain,
and the Spanish provinces, and was by many considered as a disease of
modern origin; first making its appearance in Spain, about the year 1610,
and afterwards extending to Naples, Malta, and Sicily, where it continued
to prevail for the succeeding twenty years.| This opinion, of the modern
origin of the disease, was predicated on the silence of the Arabian physi-
cians in relation to such an affection; but its correctness is invalidated by
the quotations already made from Aretaeus and others. It appears, indeed,
to have been described as early as the year 1600, by Alfonso y Pedro Vas^
quez, a Spanish physician; and between this period and the year 1666, it
called forth a great number of memoirs and treatises, from the physicians
of Spain, by whom it was described under the appellations garrotillo, tra-
badillo, morhus suffbeans^ &c.§

In the conrse of the eighteenth century, notices of the disease were
greatly multiplied, as it prevailed extensively, at different periods, through-
out the greater part of Europe. But in proportion as it became more fre-
quent in its appearance, the difficulty of tracing its history was much in-
creased, by the different appellations which were, at different times, em-
ployed to express its true character. It was particularly in the course of
this century, that originated the confusion, which has been subsequently
continued, arising from the application of the terms cynanche maligna,
angina maligna and gangrenosa, scarlatina maligna, scarlatina gangrenosa,
ulcerated sore throat, putrid sore throat, <fec. to conditions either identical,
or differing so slightly from each other, as to render it impossible to dis-
criminate between them. If, then, we admit that there is a disease cor-

♦ Etmuller de Feb. p. 202, apiid Naumann. Klinik. 61.

t Aretaeus, Lib. ii. caput, ix.

t Don Joaquin de Villalba, Epidemiologia Espanola 6 Historia Cronolbgica de las
Pestes, Contagios, &c. que ban Acaecido en Espana, torno ii. p. 18. Madrid, 1803.

§ The following list comprises most of the Spanish writers on the disease, in addi-
tion to those cited above from Bretonneau: — Gomez de la Parra, Francisco Perez Cas-
eales, Juan de Villareal, Herrera, Alonzo Nunez, Juan de Soto, Francisco de Figuero,
Lorenzo de San Miilan, Don Nicolas Antonio, Don Fernando Sola, Geromina Gil de
Pina, Nicolas Gutierre, Luis Mercado.

Geddings on Inflammation of the Throat. 75

responding to the characters proper to cynanche maligna, and independent
of scarlatina maligna, it must be confessed, that this difference has not been
kept in view by the writers of the eighteenth and nineteenth centuries who
have treated on the subject. Thus the diseases described by Huxham and
Forthergill, which are generally adopted as the type of cynanche maligna,
were unquestionably scarlatina maligna; and there is no satisfactory evi-
dence that the descriptions of Baillou, Morton, Malonin, Cotton, De Haen,
Wall, Johnstone, Grant, Bang, Aaskow, Withering, Sims; and, in this
country, of Golden, Douglass, Bard, and others, apply to a different dis-
ease. The more recent descriptions of Stoll, J. P. Frank, Reil, and of
the numerous writers of the present century, have contributed greatly to
improve our knowledge of the disease; but have left us in the same doubts
that formerly existed relative to the exact relationship between scarlatina
maligna, and the affections usually described under the names of cynanche
maligna, putrid sore throat, &c. — it being still contended by some, that
the two affections are identical.

Without pretending to discuss this question, I shall content myself with
attempting to describe the diphtheritis of Bretonneau, and the angina ma-
ligna of previous authors, which it will be sufficient for the end proposed
to consider as different degrees or stages of the same affection.

1. Angina Pseudomembranacea. — The incursion of the disease is often
very insidious. The patient experiences merely a slight sense of rawness
and heat in the throat, with a feeling of stiffness about the neck, and some
impediment in deglutition. There is, however, in many instances, no dif-
ficulty experienced in swallowing, and the chief uneasiness experienced is
a dry, raw sensation in the throat, as though the membrane had been pre-
ternaturally irritated by pepper or some other pungent substance. Some
complain, from the commencement, of languor, general discomfort, a sense
of chilliness, alternating with flushings of heat, thirst, pain of the head,
swelling and stifihess of the throat, and considerable difficulty of degluti-
tion. But this is far from being common; the patient, if a child, often
continuing to indulge in its ordinary sports, being only a little fretful and
dejected.

The condition of the mucous membrane of the fauces and tonsils ex-
hibits appearances far more characteristic of the disease. Even at the com-
mencement of the attack, these parts exhibit a deep red, circumscribed or
extended suffusion, covered with coagulated transparent mucus, often dis-
seminated in small isolated particles, of a whitish or grayish colour. As the
disease advances, the exudation, which was at first slight, becomes more
abundant, and forms a concrete pellicle, of a yellowish or grayish colour,
generally disposed, at first, in patches more or less circumscribed, which
are often a little elevated in the centre; but attenuated and flocculent at the
circumference. This pseudo-membranous pellicle is at first thin and
cribriform; but its thickness is afterwards increased by successive depo-
sites. This gives it greater firmness, and it may sometimes be detached
entire from the mucous membrane. If, however, the separation be cau-
tiously made, the pellicle will be found to adhere to the subjacent mem-
brane by numerous minute prolongations, or filaments, which seem to per-
forate the orifices of the mucous follicles. The severance of these gene-
rally produces a slight discharge of blood from the point with which they
adhered, and when they have been detached several times, the bloody exu-
dation becomes so considerable that it seems to ooze from every portion of

Monograph,

the denuded membrane. The part of the membrane from which the pel-
licle has been removed is not generally much swollen, but exhibits a dark
red colour, often variegated with points or striae of a deeper hue. In the
interstices of the patches, the submucous cellular tissue occasionally as-
sumes an cedematous condition, which elevates the corresponding portion
of the membrane, and the isolated points covered by the pellicle being de-
pressed, exhibit the appearance of ulcers, coated by a tenacious exudation.
In all, except very mild cases, the patches soon become confluent, and very
often the whole of the tonsils, the soft palate, the posterior part of the
fauces, and even the inner side of the cheeks, and the whole mouth, are
lined by a pellicular exudation of considerable consistence, which is rapidly
renewed as often as it is detached.

The adventitious deposite is sometimes pultaceous and transparent, but
in the course of the disease, it acquires greater consistence and tenacity,
and may even attain, at some points, the thickness of several lines. Its
colour also changes, becoming first ash-coloured, then brown, and finally
black; in w'hich condition, the patches are often mistaken for gangrenous
sloughs. If they be detached at this juncture, the membrane beneath will
be found of a dark-red colour; spongy, excoriated, and disposed to bleed
on the slightest touch; but in no other respect altered. The perverted se-
cretions poured out by the affected part, together with the constant oozing
of blood which now takes place, renders the breath of the patient highly
offensive, and the irritation being propagated to the surrounding parts, the
cellular tissue of the neck often becomes tumid and oedematous; the lym-
phatic and salivary glands enlarge; and deglutitipn is performed with diffi-
culty and pain.

In the early stage of the disease, the tongue is red on the borders, and
narrowed at the tip. Its surface is covered with a thin whitish pellicle,
through which the prominent red papillae project, exhibiting the appear-
ance of the small granules of a strawberry, but towards the root of the
organ, the fur is, from the commencement, of a darkish hue, and as the
disease advances, this appearance becomes more extended. Towards the
close, the whole tongue often becomes dry, scabrous, and of a dark brown
or black colour; the mouth is also dry; the teeth are covered with sordes;
small ulcers form along the edges of the tongue and upon the inner sur-
face of the cheeks; and the slightest irritation excites a discharge of blood
from nearly the whole extent of the lining membrane of the mouth and
fauces. This dryness of the mouth and tongue is far from being a con-
stant character of the disease. It is not unusual, particularly during the
early stages, for the glandular secretions of the mouth to be inordinately
increased; and in some cases, it amounts to a complete salivation. The
tonsils and soft palate are sometimes very much swollen; and occasionally
the tongue is so much tumefied, as to fill the whole mouth, which, in con-
sequence of the inability of the patient to breathe through the nose, is
kept widely extended.

The disease is seldom confined to the mouth and fauces, but extends
into the nose, along the eustachian tubes into the ears — into the larynx,
and down the pharynx and cesophagus. The implication of the Schneide-
rian membrane of the nose, is indicated by a thin ichorous discharge, pro-
ducing considerable soreness and excoriation at the apertures, and by so
much tumefaction of the membrane itself, as to render it impossible for the
patient to breathe, except through the mouth. This keeps the longue and

Geddings on Inflammation of the Throat.

buccal cavity in a constant state of dryness, which adds greatly to the
discomfort of the patient. Sometimes the discharge from the nose is
thick and flocculent, and the effort to expel it not unfrequently occasions
more or less blood to be poured out, which, mingling with the vitiated
secretions, imparts to them a dark colour. Profuse epistaxis may occur
under the same circumstances; and in all cases the discharge from the nosie
exhales a peculiar sickening, fceiid odour.

When the pseudo-membranous inflammation extends into the larynx,
it gives rise to all these symptoms of croup; as hoarseness, a shrill cough,
great difficulty of respiration, and in some cases, complete aphonia. This
circumstance has, doubtless, confirmed Bretonnean, and others, in the
belief, that diphtheritis and croup are but one disease. In both affections,
there is often formed a tough pseudo-membranous deposile upon the sur-
face of the lining membrane of the larynx, trachea, and bronchial tubes;
but although there is this correspondence in the anatomical characters of
the two diseases, as well as in some of the leading symptoms, there is an
essential difference in some of the principal elements of their pathalogy.

When the eustachian tube is involved, there is pain of the ear, with
impairment of hearing; and in some cases, the use of the organ is perma-
nently destroyed by obliteration of the tube. If the inflammation should
spread into the pharynx and oesophagus, it will necessarily occasion a great
feeling of soreness along the course of these organs, and acute pain,
whenever an attempt is made to swallow. The false membrane, however,
seldom extends far into the gullet, even when the inflammation producing
it, spreads to the stomach and intestines.

A remarkable peculiarity of this diphtheritic inflammation is, that while
its principal seat is the parts about the throat, it often seizes upon remote
portions of the surface of the body. The contour of the anus; the aper-
tures of the genito-urinary organs; the external meatus of the ears; the
folds of the groins; and other similar parts, often exhibit excoriations,
caused by a thin pellicle of false membrane, analogous to those which
form in the throat. It is remarked by Trousseau, that he never witnessed
this condition upon the skin, except in situations where the epidermis had
been previously removed, or ulcerated; consequently when it had been
made to assume some of the characters of a mucous membrane.* Blis-
tered surfaces, especially, are liable to become covered with a pulpy pel-
licle, which sometimes assumes a dark colour; and leech-bites, or even
slight excoriations of the cuticle, often run into an unhealthy form of ulcer-
ation, or give rise to an eruption of vesicles, surrounded by an inflamed
areola.

The course of this form of angina is generally slow. The disease sel-
dom reaches its height before the seventh or eighth day, and cases of much
intensity seldom terminate in less than a fortnight, or three weeks. The
fever, which is present from the commencement, generally continues with
more or less variation through the entire course of the disease. But the
inflammation and fever, which during the first stage proceed with consi-
derable rapidity, show a tendency to become stationary after the lapse of
a few days. The heat of the skin, when it is increased, is generally pun-
gent at first; but in some cases, it is but little altered. The thirst is ur-
gent; and the pulse is frequent, irregular, irritable, and without much

* Dictionnaire de Med. 2d edit. Art. Diphtherite.

Monograph,

force or volume. The eyes and countenance are sometimes flushed; but
in many cases, the latter is pale, swollen, and wears an expression of sad-
ness, and dejection. These symptoms are increased as the disease ad-
vances; but the heat of the surface, if considerable during the first stage,
undergoes a sensible abatement, at the same time that the skin assumes a
dingy appearance, and loses its natural elasticity.

There is frequently nausea, epigastric tenderness, and great precordial
oppression. The bowels are generally constipated at the commencement;
but it is not unusual for diarrhoea to supervene in the course of the dis-
ease; and in the last stages, it sometimes becomes colliquative; rapidly
prostrating the powers of life. The secretions are perverted in quantity
and quality, and the urine, especially, is scanty and dark coloured.

It has been remarked that delirium is seldom observed as a concomi-
tant of diphtheritis. I’his assertion should be admitted with considerable
limitation, as the nervous system is, in a majority of cases, extensively
implicated. Very often, however, this complication is indicated rather by
a state of general torpor, or prostration of nervous power, than by evi-
dences of cerebral excitement. In bad cases, the muscular energy is
generally prostrated from the commencement, and in the latter stages, it
is so far impaired, that the patient is rendered completely helpless, 'rhe
general, as well as tlie local symptoms, vary greatly, however, according
to the violence of the disease. In mild cases, the febrile phenomena are
inconsiderable, whereas in those of greater intensity, frequent excerba-
tions are observed — generally two or three in the twenty-four hours.*

In those cases in which the disease extends to the larynx, the life of the
patient is always endangered; for, independently of the symptoms of croup
already alluded to, which are apt to be developed under such circum-
stances, the inflammation is liable to spread into the bronchial ramifica-
tions, giving rise to all the phenomena of bronchitis, or pneumonia. This
complication takes place, according to Guersent, about the seventh day,
and is so insidious at the commencement, or is so masked by the local
affection of the throat, that the fever and cough are apt to be ascribed to
the latter cause. Indeed, cases not unfrequently occur, in which the affec-
tion of the fauces is very slight, while the larynx is so intensely impli-
cated, that the disease terminates fatally, \yith all the symptoms of croup,
within a few hours after the attack. This did not escape the observation
of Hippocrates, and is noticed by him, both in his aphorisms and prog-
nostics; in the last of which he remarks — “ Anginae horridissimae sunt,
et citissime occidunt, quae neque in faucibus quicquam conspicuum faci-
unt, neque in cervicern, verum plurimum dolorem exhibent, et erecta cer-
vice spirationem inducunt — hae enim eodem die suffocant.”

In such instances, the cough is not so clearly guttural as in croup, nor
is there so much hoarseness and aphonia as in that disease. The expec-
toration is generally tough and streaked with blood; sometimes frothy;
percussion and auscultation reveal the presence or absence of the physi-
cal signs of bronchitis or pneumonia; and there is generally considerable
fever, which presents regular evening exacerbations.

When the disease terminates favourably, the pultaceous, or pseudo-
membranous deposite is generally cast off', leaving a clear, moist, red sur-
face beneath, upon which there is no disposition to form a new croup. It

* Guersent. Diet, de Med. 2d edit. Art. Angine Couenneuse.

Geddings on Inflammation of the Throat, 79

is sometimes detached in flakes — but more frequently it seems to be par-
tially liquefied, and is thrown off in force of expectoration. The tongue
becomes clean, and moist upon the edges, and expanded at the tip; the
expression of the countenance assumes more animation; ihe general feel-
ing of discomfort abates; and often a genial moisture diffuses itself over
the surface of the body — convalescence then commences, but is often
slow, and when the disease is associated with scarlatina, relapses are
very apt to take place, or the life of the patient may be destroyed by
dropsy, even after convalescence has set in. An unfavourable issue is
indicated, by an aggravation of the leading symptoms of the disease — es-
pecially by the supervention of active delirium, or coma — extreme pros-
tration of strength, great dryness and blackness of the mouth and throat,
wasting diarrhoea, and a general tendency to dissolution of the solids and
fluids. Under such circumstances, the disease assumes all the characters
of angina maligna, which, though by many considered as a distinct dis-
ease, I shall describe here as constituting merely a variety of diphthe-
ritis, or angina membranacea.

2. Angina Maligna — Angina Gangrenosa — Cynanche Maligna,

Many writers continue to describe a disease under this name, which
they consider distinct from scarlatina maligna. The putrid sore throat of
Fothergill and Huxham, however, which all acknowledge as the type of
cynanche maligna, corresponds in every essential particular with the ma-
lignant forms of scarlatina. It is nevertheless true, that the pseudo-mem-
branous angina sometimes assumes the same malignant character, and ia
this respect only, is it proposed to notice it under the present head.

The invasion of angina maligna does not differ essentially from that
of the ordinary forms of diphtheritis, and any dissimilarity that occurs,
relates more to intensity than character. 'I’here is the same languor
and dejection — prostration of strength, uneasiness about the throat — and
in some instances, a sense of chilliness preceding the development of the
febrile phenomena. The glands about the throat, the tonsils especially,
are generally more swollen from the commencement. The face exhi-
bits a bloated, bronzed aspect; the eyes are heavy, lustreless, and watery;
and the breath offensive. The fauces exhibit a deep red, or purple
suffusion, upon which small patches, or flocculi, of a pulpy pseudo-mem-
branous consistence are deposited, 'fhese are sometimes white, but
more frequently of a dull ash colour, which in a short time is changed
to brown or black. Wlien first forme«l, they adhere to the surface of the
mucous membrane with considerable tenacity, and when separated, leave
it raw, dark coloured, and bloody. The parts speedily assume a dark
sloughy condition; the adventitious deposiie, together with the portions
of the mucous membrane, is thrown off in form of flocculi, or shreds,
which exhale a putrid, cadaverous odour; and the sloughing process
spreads rapidly into the substance of the tonsils, the soft palate, and
occasionally, also, into the parotid glands and cheeks. There is, like-
wise, almost from the commencement, a dark-coloured sanious discharge
from the nose; dark-coloured vesicles form about the margin of the lips,
the angles of the mouth, the inner surface of the cheeks, and upon the
tongue. These discharge their contents, and take on a sloughing ten-
dency. A similar condition is occasionally developed upon different
portions of the skin. In a case which recently fell under my observa-
tion, the whole of the upper part of the tongue was thickly clustered

Monograph.

with small vesicles, similar to those produced by sprinkling boiling water
upon the cutaneous surface. In the epidermis described by Golden, sores
like those in the throat, formed behind the ears, on the genitals, or other
parts of the body, and in these cases, there was sometimes no ulcera-
tion in the throat. Petechia are also sometimes observed, They were
almost constantly present in the epidemic described by Short; and Wall,
as well as many other writers, describes them as of common occurrence.

This form of the disease, like the preceding, is liable to implicate the
larynx and air passages, and to extend its influence to the mucous mem-
brane of the pharynx, (esophagus, stomach, and intestines. Nausea, vomit-
ing, and epigastric oppression, are, indeed, frequently present from the
commencement, and if the disease is not at first attended with diarrhoea,
this symptom sooner or later supervenes. The dejections are thin, co-
pious, sanious, and intolerably offensive. They are often so acrid as to
excoriate, and inflame, the contour of the anus; and in bad cases, copious
hemorrhages take place from the bowels, which have been ascribed to the
formation and detachment of sloughs in the intestines, similar to those
which are developed in the throat.

The febrile symptoms are generally marked by symptoms of conside-
rable intensity, during the first and second days. The skin is hot and
pungent, and the fever exacerbates towards evening. The mouth is parch-
ed; the thirst urgent; and the tongue soon becomes dry, brown about the
root; finally black and scabrous — while sordes of the same colour invest
the teeth and gums. The latter are generally spongy, tumid, and dis-
posed to slough; and in some cases, gangrenous eschars involve the cheeks
to such an extent, as to traverse their entire thickness. I have recently
attended a case in which a rounded perforation was formed in the soft
palate. Death took place in the advanced stage of the disease, by hemor-
rhage from the mouth— probably in consequence of the sloughing of the in-
ternal carotid artery — as the child died almost immediately after the irrup-
tion of the blood.

When the throat is much swollen, the difficulty of deglutition is ex-
treme, and the enlargement of the glands about the neck, sometimes im-
pedes the return of the blood from the brain, thereby giving rise to great
turgescence of the vessels of the face and eyes, and considerable cerebral
disturbance. Delirium, indeed, often exists from an early period, and
although the febrile symptoms, which are at first urgent, soon subside
into a low typhoid state, the delirium either continues, or gives place to
a state of stupor or insensibility.

Angina maligna has no definite duration. It may destroy life in a
few hours, or be protracted through a term of two, three, or four weeks.
It generally reaches its height by tlie fifth or sixth day, and it rarely hap-
pens, that symptoms of high reaction continue beyond this period.

Prognosis. — The prognosis is generally unfavourable when the symp-
toms assume a formidable character at the end of the first week, and well
grounded fears of an unfortunate issue may be entertained, when a mark-
ed tendency to dissolution of the solids and fluids is developed — espe-
cially, if with this, there be either extreme prostration of the vital pow-
ers, or serious complications arising from, and extension of the disease to
the respiratory and digestive organs. A favourable termination may be
anticipated, when the disease extends beyond the first septenary period,
without the supervention of formidable symptoms, particularly if the se-

Geddings on Inflammation of the Throat, 81

paration of the sloughs have a clean healthy surface beneath. The ab-
sence of complications with laryngeal and gastro-intestinal symptoms is
also favourable, as are likewise a diminution of the frequency of the
pulse, a subsidence of the tumefaction of the throat, and of the dryness
of the tongue, with cessation of the diarrhoea, and the establishment of
more consistent and healthy dejections from the bowels.

nSRtiology of Angina Membranacea^ and Angina Maligna.

Both grades of the disease may appear under either an epidemic or a
sporadic form. They occur most frequently as an epidemic, confined to
districts of small extent, or to cities, towns, and villages. Children are
much more liable to be attacked than adults; and in them, it always
assumes greater violence, although adults, contrary to what was asserted
by Fothergill, often fall victims to its ravages. It has been affirmed that
females are more liable to be attacked than males; but there is some rea-
son to doubt the correctness of this opinion.

The disease is most prevalent in autumn and spring, and it has been
generally said to occur most frequently, when the seasons are damp and
rainy, with the long continuance of a heavy, cloudy, atmosphere. Such
a coincidence has certainly been observed in many epidemics, yet the
exceptions are too numerous to justify the conclusion that these condi-
tions of the atmosphere are the essential causes of the disease. It is re-
marked by Trousseau,* that in 1825, a year remarkable for its dryness,
the communes situated north of Orleans, were ravaged by diphtheritis,
and it was observed, that the intensity of the epidemic did not reach its
height in one commune, at the same time it did in another, placed under
the same circumstances. Low, damp and marshy situations, it has also
been affirmed, are more liable to the disease, than such as are high and
arid. Such an inference must be received with some qualification, since
it is proved by the history of many epidemics, that even the most salu-
brious and elevated localities, are not exempt. Such was the case in an
epidemic observed by Trousseau, while the marshy districts of the same
region enjoyed a perfect immunity. Poverty, or neglect of cleanliness,
a want of ventilation, and an atmosphere vitiated by crowding together a
number of persons, particularly children, as is the case in boarding schools,
must be regarded as active predisposing causes. Yet the disease not un-
frequently prevails to a great extent, where most of these circumstances
are absent, and among those who enjoy every comfort and luxury of life.
Within the last eighteen months, during which time diphtheritis has been
prevalent in Charleston, I have not observed that its attacks were more
frequent among the children of the poor, than those of the opulent.

The difficulty of referring the disease to any ordinary cause, and the
circumstance of its spreading through whole families and communities,
have induced many to refer it to a specific contagion. The sentiments of
the profession on this question are conflicting, and owing to the disease
having been confounded, until recently, wdth scarlatina, the documentary
evidence is in a high degree unsatisfactory. Unfortunately, but little of it
is available in forming a decision of the question, and if we confine our
attention to the testimony of writers since the time of Bretonneau, the first
to draw a distinction between diphtheritis and scarlatina, we shall find it
contradictory. Trousseau is strong in his belief in a specific contagion.

* Dictionnaire de Med. 2d edit. Art, Diphtherite, tome x. p. 392.

82 Monograph,

He affirms that it is sufficient for one individual labouring under the disease, to
be introduced into a family, to insure its development under all its forms.
The cutaneous form of diphtheritis, especially, he thinks is very liable to
be communicated by contact; and amongst the poorer classes, where the
same bed, clothing, and utensils, are used by all, the virus will thereby
become so accumulated, as to render it very liable to attack all the mem-
bers of a family. He inform us, that in 1828, he knew thirteen indivi-
duals, out of seventeen, fall victims to the disease. He found, however,
that inoculation in the arm, the tonsils, and the soft palate, with a lancet
smeared with the matter of a false membrane taken from a diphtehritic
sore, did not produce the disease. In the arm, it gave rise to a small ves-
icle, but produced no effect upon the mucous membrane. Similar experi-
ments were made upon animals by Bretonneau, but without communicat-
ing the disease. Yet it is stated that a boy, at the College of Fleche, who
was affected with chilblains, was attacked with pseudo-membranous es-
chars between the toes, in consequence of walking barefoot over the floor of
the infirmary, which was covered with the sputa of a comrade labouring
under diphtheritis.*

On the other hand, it has been contended that the simultaneous appear-
ance of the disease in several members of the same family, or the occur-
rence of a succession of several cases among individuals inhabiting the
same locality, do not justify a belief in contagion, since similarity of
organization and temperament, which often exists under such circum-
stances, would be apt to predispose those possessing it, to a similar form
of disease, on their being exposed to an epidemic influence. It has been
■often observed, moreover, that when the disease breaks out in a family, or
school, only a part of the members sicken, although free intercourse exists
between them; that when persons already afiected with it, are removed
from the atmosphere where they contracted the malady, they do not
transmit it to others, w’ho may be brought in relation with them. Bour-
geois,f has mentioned some interesting examples of this kind, which oc-
curred during the epidemic of St. Denis, and in several instances which
have fallen under my observation, during the present and preceding sea-
sons, one, two, or more of the members of a family have been seized by
the disease, while all the rest have escaped, although free intercourse
existed.

An examination of the whole grounds, seems to justify the conclusion,
that diphtheritis, in both its forms, depends upon an epidemic constitution.
Yet under particular circumstances, as where many persons are crowded
together, where ventilation is imperfect, and cleanliness is neglected,
there cun be no question of the generation of a contagious influence,
capable of transmitting the disease from one person to another. Breton-
neau, Trousseau, Bourgeois, and Guersent, all mention instances, which
must be deemed conclusive upon this point.

Pathology. — The anatomical characters of diphtheritis, in both its
forms, have been so fully described above, that little remains to be said
upon that subject. The most striking feature is, the pultaceous, or pseudo-
membranous deposite upon the mucous membrane of the throat and adja-
cent parts — sometimes preceded, or even accompanied by small vesicles,

* Guersent. Diet, de Med. Art. Angina Membranacea.

t Memoires de I’Academie Roy ale de Medecine.

Geddings on Inflammation of the Throat,

of a whitish, or purple colour. The membrane is also inflamed, and raw
upon the surface, but is far less frequently ulcerated, than was formerly
supposed. In the proper pseudo-membranous form of the disease, gan-
grene is of rare occurrence, although the false membranes very often
assume a dark, or black colour, and a flocculent appearance, from which
they might, on a superficial examination, be taken for gangrenous eschars.
Gangrene and sloughing are of common occurrence in angina maligna,
and often extend deeply into the surrounding parts. Most of the other
anatomical characters observed in the disease, relate to the accidental com-
plications. They consist, chiefly, of lesions of the respiratory, digestive,
and auditory apparatus, in which traces of inflammation and false mem-
branes are often discovered.

The pathology of the disease is difficult to explain. There is obvious
hyperemia of the mucous membranes, with impairment of nervous en-
ergy. Yet there is something peculiar in the inflammation, which im-
parts to the disease all its distinguishing characters. Bretonneau and his
followers tell us, it is a specific inflammation; but this furnishes no expla-
nation of the several elements composing the morbid process. Broussais,
Emangard, and others, affirm that diptheritis is primarily a gastro-enteritis,
the affection of the throat being merely a complication. By the first of
these writers, it is said to be a species of typhus, with predominance of
guttural inflammation; and in speaking of the cause t)f the fever, he af-
firms that it is a gastro-enteritis, such as is observed in low and humid situa-
alions — upon the borders of rivers, in the vicinity of marshes; in all loca-
lities, in short, where the temperature is depressed, and the air charged
with humidity, malarious exhalations from animal and vegetable substances
in a state of decomposition, fogs, &c.*

Gastro-enteritis is certainly one of the most frequent complications of the
disease, but cannot be considered the source of its leading peculiarities;
nor can all its local phenomena be explained by a reference to a state of
acute hyperemia of the nervous membrane of the fauces, with an exudation
of coagulable lymph, as maintained by Andral. There is something in the
predisposition, which impresses upon the inflammation a character totally
distinct from that of ordinary phlogosis. Naumann supposed that some
change is wrought, by the epidemic influence, upon the properties of the
blood, rendering its albuminous constituents incapable of being held in so-
lution by the serum, in consequence of which the former exude upon the
surface of the mucous membranes, in form of the pellicular deposite which
characterizes the disease.! Consequently, when this predisposition exists,
the occurrence of gastro-intestinal irritation will give rise to pseudo-mem-
braneous deposites on the surface of the inflamed mucous membrane.

In connection with this hypothesis, I may allude to the researches of
Donne, which go to prove that, in the course of disease, the secretions be*
come highly acid, so that, if we admit as valid the opinion of Raspail, that
fibrine is merely albumen coagulated by an acid, we thus acquire a reason
why, as represented by Naumann, the serum loses its power of holding
the albumen in a state of solution. These opinions are not offered as es-
tablished facts, but only as conjectures, which, however, if found to be

* Cours de Pathologie et de Therapeutique Generales, tome i. p. 350.

t Handbuch der Medecinischen Klinik, bande iv. p. 81. Also, Hecker’s Wisscn.
schaftlichen Annalen.

Monograph,

correct by subsequent investigations, cannot fail to have an important in-
fluence in the explanation of the formation of false membranes, and many
other adventitious products.

Be this as it may, the cause of the disease seems to exercise its first in-
fluence upon the ganglionic nerves, impairing their energy, and perverting
their powers. A consequence of this is, a deterioration of the nutritive
and secretory functions. The constituents of the blood are changed, either
in quality or their relative proportions. The plastic forces are deranged,
and the inflammation which supervenes is engrafted upon an organization
incapable of sustaining those changes, by which restoration is so speedily
effected under ordinary circumstances. The venous capillaries seem to be
more deeply implicated than the arterial, and the powers of resistance or
reparation being feeble, in consequence of the impairment of nervous en-
ergy, there is a strong tendency, on the part of the solids and fluids, to run
into a state of dissolution.

Treatment. — Few diseases have been treated by such opposite methods
as the one now under consideration. The conflicting opinions on this
subject are a natural consequence of the diversified pathological views en-
tertained by different authors; but have originated, in part, no doubt, from
the dissimilar character of different epidemics. This latter circumstance
has led some to regard it as a purely inflammatory disease, requiring a
strictly antiphlogistic treatment. Others have had their whole attention
taken up with its asthenic or adynamic character, and have, consequently,
advised a stimulant or tonic practice; while a third class, making allow-
ance for its variable nature, and watching its several changes, have pursued
a mixed treatment, adapted to circumstances as they arise. The last is cer-
tainly the most rational procedure, as it is in strict accordance with the
character of the disease.

In mild cases, especially such as are sporadic, gentle aperients, diluents,
stimulating frictions to the throat, and emollient detergent gargles, will ge-
nerally suffice to effect a cure. But where the febrile phenomena are ur-
gent, with a high degree of inflammation of the throat, associated with a
pultaceous or pseudo-membranous exudation, more active means will be
demanded.

It then becomes a question of the propriety of resorting to the abstrac-
tion of blood, and other antiphlogistic remedies. Authority is strong, both
for and against general blood-letting. Bretonneau, Trousseau, Bourgeois,
and others, assure us that they found it altogether unavailing, and, in many
cases, decidedly injurious. They make the same remark in reference to
leeches applied to the throat. Many practitioners of equal respectability
and experience, on the other hand, declare that they derived essential ser-
vice from both general and local bleeding, when employed under proper
circumstances. It is not impossible to reconcile these conflicting state-
ments. Great diversity is observed in the phenomena of different epide-
mics, and also in the cases which occur under the same circumstances of
time and situation. In stout, robust adults, and in vigorous children, pos-
sessing an active, sanguine temperament, if there be great heat of the
skin, with an active pulse, and violent inflammation and swelling of the
throat, the lancet cannot be well dispensed with in the early stage of the
disease; and great benefit will be derived, under the same circumstances,
from the application of leeches to the throat, and behind the angles of the
jaw. This treatment was pursued with happy effect, by Gendron and

Geddings on Pseudomembranous Inflammation of the Throat, 85

Guimier, in the same epidemic in which Bretonneau affirms that blood-
letting was injurious. Bleeding was also practised by many of the older
physicians, in the treatment of angina maligna, and was occasionally re-
sorted to, by Fothergill and Huxham, in plethoric individuals. Its admi-
nistration should be confined to the fiyst stage of the disease, wdiile the
febrile symptoms are active, and to individuals possessing a vigorous circu-
lation, with sufficient tolerance to endure the loss of blood, without the risk
of prostrating the vital powers beyond recovery. Leeches may be often
employed with advantage, where the lancet would be inadmissible. Neither
can be prudently resorted to where the vital powers are already depressed;
where the disease has existed for some^ time; where the skin is cool, the
pulse feeble, and the fauces of a dark colour. Under these circumstances,
even leeches will be injurious, and the bites are apt either to slough, or
take on a diphtheritic form of inflammation. When the disease is com-
plicated with gastro-enteritis, leeches may be applied, also, over the epi-
gastrium. Emangard recommends them to be applied to this region in
ordinary cases, upon the supposition that the disease is primarily a gas-
tro-enteritis.

Emetics were formerly more employed than at the present time. In
the forming stage of the disease, if there be no gastric complication to con-
tra-indicate their administration, they will often render essential service by
their revulsive influence; and, at a later period, they sometimes render the
breathing and swallowing easier, by expelling shreds of false membrane,
and the viscid secretions that accumulate about the throat. Ipecacuanha,
or sulphate of zinc, will be the best articles to excite vomiting; but neither
of them should be employed when there are symptoms of gastro-enteritis.

The bowels should be kept soluble during the whole course of the dis-
ease. Mild saline aperients are best adapted to the fulfilment of this indi-
cation during the early stages; and, at a later period, small doses of castor
oil, or laxative enemata, may be substituted. Active cathartics, especially
of the drastic clasSj are never admissible, as they tend, inevitably, to
increase the gastro-intestinal irritation, and hasten the development of diar-
rhcea. Calomel, however, has been strongly recommended by respectable
authority. Its powers were long since extolled by Douglass, Bayley, and
Holyoake, in this country, in the angina maligna; and it has recently been
commended, in high terms, by several European writers. Bretonneau
administered it in doses of three grains, every two hours, so that more than
a drachm was often taken in the course of the day. He remarks that it
exercised a striking influence in cleansing the throat and mouth of the false
membranes, and producing an amelioration of all the symptoms. Bour-
geois, Roche, and others, who resorted to it, under similar circumstances,
derived no benefit from its employment, and its use has been abandoned by
most of the recent writers on the subject. It should not be resorted to
except in the early stage of the disease, and even then, it should not be
employed when there are symptoms of high gastro-intestinal irritation.
With these restrictions, it may be employed in alterative doses, combined
or alternated with mild aperients. If there be any cases calling for the
free administration of calomel, they are those in which the inflammation
extends into the larynx, producing urgent symptoms of croup. Under
these circumstances, if the subject be vigorous, and the disease in its first
stage, large doses of calomel may be given, in combination with tartafized
antimony or ipecacuanha.

No. XLVII.—May, 1839.

Monograph,

Proper attention should»be paid to the skin in every stage of the dis-
ease. At the onset, the tepid bath may be employed with advantage; and
it will be useful, as long as the heat continues above the natural standard,
to keep the surface constantly sponged with cold vinegar and water, or
spirits and water. Cold acidulated, or emollient drinks, should be taken
freely, and when there is much gastric irritation, with intense thirst, the
patient will be much refreshed by taking frequently into the mouth, small
fragments of ice. The use of this agent has been highly recommended
by Dr. Jackson, of Northumberland, in scarlatina, and it is not less effica-
cious in the present disease. It should not be employed, however, when
the larynx and bronchia are implicated. I’he mild salines, possessing a
slight excess of alkalinity, may also be employed with advantage during
the febrile stage. The most appropriate will be, the common neutral
mixture, the tartrate of potash, the ordinary eflervescing draught, or soda
powders.

Much difference of opinion exists, in reference to the application of
revulsives to the throat. Blisters and sinaplasms have been by some con-
sidered injurious — their tendency, according to those who object to their
employment, being, to excite a diphtheritic form of inflammation in the
part to which they are applied, or to give rise to gangrene. This is un-
doubtedly true in the advanced stage of the disease, after symptoms of
colliquation have commenced. They should, therefore, be resorted to
\yith great caution under these circumstances. At an earlier period, they
may be employed with less risk; but in most cases, their place can be very
well supplied with rubefacients. 'Bhe throat may be rubbed with equal
parts of olive oil and aqua ammonise, with oil of turpentine, or common
cainphorated soap liniment, combined with aqua ammoniae and laudanum.
A very efficacious liniment for this, and other purposes, may be composed
of four ounces of strong aqua ammoniae, and two ounces, each, of cologne
water and camphorated spirits. In urgent cases, however, blisters may
be applied to the throat, the nape of the neck, or the extremities— -the
back of the neck should be generally preferred. Hirschel, Pouteau, and
Mours found them highly serviceable when there was great swelling of
the throat, accompanied with an urgent sense of suffocation. Warm sina-
pized pediluvia afford great relief, and should be repeated frequently du-
ring the course of the disease.

As soon as the powers of life manifest a disposition to fail, a more
cordial course of treatment will be demanded. This will be particularly
necessary, when the throat assumes a gangrenous aspect, especially, if
associated with this condition, there is coldness of the skin, feebleness of
the pulse, petechiae, and other ataxic symptoms. The best remedies
under these circumstances will be, the acetate of ammonia, either alone,
or combined with an equal quantity of aqua camphorae; carbonate of am-
monia; infusion of serpentaria; d^^coction of bark with aromatics; sul-
phate of quinine; and the muriatic, nitric, or sulphuric acids. In the
ataxic and gangrenous forms of the disease, these remedies properly
employed, will be productive of the happiest effects, and great benefit
will be derived, under the same conditions, from the discreet use of wine.
It may be used in form of whey, or added to the farinacious articles of
diet used by the patient. Great care, however, must be observed, not to
resort to the stimulating treatment too early, and it may be proper to
remark, that this practice will seldom be demanded, except in the last

Geddings on Pseudomembranous Inflammation of the Throat. 87

stages of that form of the disease described under the appellation angina
gangrenosa. In this stale of the malady, a decoction of bark, combined
with camphor, may be given in form of enemata, without the risk of pro-
ducing dryness of the tongue, and other bad symptoms which some-
times follow its internal administration. A mixture of capsicum, com-
mon salt, vinegar and water, has been much extolled in this form of the
disease. Stewart, who was one of the first to employ it, used three tea-
spoonfuls of capsicum, and two of common salt, beat into a paste, to
which half a pint of boiling water, and the same quantity of good vine-
gar were added — the last after the infusion had become cold. Of this
mixture, a tablespoonful was given to an adult, every half hour. It was
administered to about four hundred patients, in the island of St. Chris-
tophers, by Mr. Stephens, and under its employment, many recovered,
who had the disease under its most appalling forms.* The same prac-
tice tias been very favourably noticed by several writers of respectabilit)”,
and I remember an epidemic which prevailed several years ago in the
interior of South Carolina, in which, with free gargling with the same in-
fusion, the remedy was found highly serviceable.

Detergent gargles have always occupied a prominent rank in the treat-
ment of angina maligna. Those most frequently employed are, alum,
myrrh, the mineral acids, and infusion of bark. They may all be used
with advantage, under proper circumstances; but within a few years, a
more energetic locaC treatment has been extensively pursued, and in the
hands of many physicians, particularly the French, has been confided
in, almost to the exclusion of constitutional remedies. It consists of cau-
terizing the throat with strong muriatic acid, or the nitrate of silver. Bre-
tonneau employed, at first, one part of muriatic acid, to two or three of
honey, with which the throat w'as freely cauterized, once or twice a day,
by means of a sponge probang, or a pledget of lint. He subsequently
used the pure acid of the shops undiluted, in the same manner. The
practice has been highly commended by Guersent, Bourgeois, Trousseau,
Lepage, and several modern writers. When this disease exists under a
mild form, the acid should be diluted to adapt it to the susceptibility of
the parts, and any inflammation excited by the strong acid, must be com-
batted by emollient gargles.

The nitrate of silver, both in solution, and in its solid form, has been
lately much employed under the same circumstances. It was first in-
troduced into practice in France, by Gendron, but was employed by
Mackenzie, about the same time in England. It is said to be more effica-
cious, even, than the muriatic acid — provingspeedily effectual in destroying
the false membranes, rendering the separation and swallowing easier, and
imparting a more healthy character to the surface of the inflamed mucous
membrane. This article, applied directly to the affected part, in the solid
form, by means of a port-cra5mn, or in solution, in the proportion of from
ten to twenty grains to the ounce of water, has displayed the most bene-
ficial results in the hands of Guersent, Gironard, Guimier, Authenac,
David, Baudelocqae, Bridel, Beldon, and others. When used in the
liquid form, a sponge probang should be dipped in the solution, and
slightly squeezed, to prevent any of the fluid from running into the pha-
rynx. With this, the tonsils, soft palate, and fauces, should be gently
touched, two or three times a day — the tongue being depressed by means

* Edinburgh Medical Commentaries, Dec. ii. vol. iii. p. 75.

Monograph.

of a spatula, so as to bring the diseased parts fully into view. When I
wish to employ the solid nitrate of silver, which is much to be preferred,
instead of employing the port-caustic, which is attended with the risk of
the caustic breaking, and falling into the throat, I reduce the substance to
powder, and roll the probang, previously moistened with mucilage of
gum arabic and squeezed in it, until a sufficient quantity of the powder
adheres to the surface. It is then brought to bear upon the diseased
pans, as in the preceding case. The patient must be cautious not to
swallow, and to obviate any mischief from this cause, the throat should
be gargled with tepid water, or some other fluid, after each cauterization.

Diphtheritic inflammation of the throat has been unusually prevalent in
Charleston, within the last twelve or eighteen months, during which pe-
riod, it has been intercurrent with scarlatina, if not a modification of that
disease itself. Having had occasion to treat a great many cases, present-
ing almost every degree of intensity, from the mildest, to the most severe,
I have given the caustic practice a pretty full trial, and with a success far
beyond what I had previously realized under the ordinary modes of
treatment. In many cases, even of great violence, none but the mildest
constitutional treatment was instituted — which, with the application of the
nitrate of silver, or the muriatic acid, was found to conduct the disease to
a favourable issue. In one case, in which both sides of the throat were
affected with great intensity, I determined, with the view of testing the
efficacy of the nitrate of silver, to limit its application to one side. In
pursuance of this intention, the caustic was applied to the left side, which
was most severely affected, while for the right, no local treatment was in-
stituted, except emollient gargles. The disease was arrested on the side
to which the caustic was applied, by the fifth day, while on the right, it
continued until the eight.

Other escharotic applications have been advised with the same view—
as powdered alum, calomel and sulphate of copper. These substances,
reduced to an impalpable powder, have been recommended to be blown
into the throat, by means of a quill, or a glass tube. The two first arti-
cles have been highly recommended by Bretonneau, Guersent, and Bour-
geois; and we are informed by Gmelin, that sulphate of copper is much
used by insufflation, in some of the southern provinces of Russia. The
great inconvenience attendant upon blowing these fine powders into the
throat is, that portions of them are apt to pass into the glottis, and occa-
sion distressing cough. This may be obviated by incorporating them
with some glutinous substance, in which form, they may be applied to
the affected part by means of the probang. Borate of soda was found
serviceable by Bourgeois in cleansing the throat; and Guersent and Roche
recommend a gargle of chloride of soda, of the strength of one drachm
of the liquid to four or five ounces of water. When the patient is unable
to gargle with the solution, it may be injected into the throat with a
syringe — the nose being closed, to prevent its too ready escape. I have
sometimes used, for the same purpose, tincture of cantharides, either pure,
or diluted with an equal quantity, or two-thirds of water; and there is
reason to suspect, that creosote, properly diluted, might prove beneficial
in some cases. Bourgeois mentions the case of a female, who, obsti-
nately refusing to submit to medical treatment, relieved herself of a very
severe attack of the disease, in eight or ten days, by gargling with strong
vinegar.

Charleston, January, 1839.

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(Robt.) Observations on the sore throat in the north of Scotland,

in 1777. 8vo. London, 1778.

Johnstone. (Jas.) Treatise on the malignant angina. 8vo. Worcester,

1779.

Taylour, (J.) De cynanche gangrenosa, (Webster. Thes. Ed. i.) Edin-
burgh, 1780.

Toulmin, (G. H.) De cynanche tonsillari. (Webster Thes. Ed. i.) Edin-
burgh, 1780.

Middleton. (Peter) Letter to Mr. R. Bayley on the croup, New York, 1780;
republished in New York Med. Repos. 3 Hex. ii. 347.

Bayley. (Richard) Cases of angina trachealis, with the mode of cure, in a let-
ter to Wm. Hunter, M. D. New York, 1781; republished in New York Med.
Repos. 2: Hex. vi. 331 and 3 Hex. ii. 345.

Goldhagen. De anginx gangrenosx differentiis. 4to. Halle, 1783.

Pasqual y Rubio. (J. A.) Tratado del garotillo maligno ulcerado, ^c, 4to.
Valencia, 1784.

Skeete. (Th.) Experiments on Bark, with remarks on putrid sore throat, <^c,
London, 1786.

Perkins. (W. L.) jin essay for a nosological and comparative view of the cy-
nanche maligna. 8vo. London, 1787.

Fothergill. (J.) Jin account of the sore throat with ulcers, 8vo. London,
1788.

Rowley. (W.) Essay on the malignant ulcerated sore throat. 8vo. London,
1788. .

Reeve. (Th.) An essay on the erysipelatous sore throat. 8vo. London, 1789.

Suarez Barbosa, (A1.) De angina ulcerosa, annis 1786-7, apud Leiriam epi-
demice grassante commentatio, Lisbon, 1789.

Schmid, (J.) De angina. (Eyerell ii.) Vienna, 1790.

Baylies. (Wm.) An account of the ulcerated sore throat, as it appeared in
the town of Dighton, in the years 1785-6. Massachusetts Med. Communica-
tions, i. 41. Boston, 1790.

Clark. (John) Observations on fevers, ^c, and on scarlet fevers with ulcerated
sore throat. 8vo. London, 1792.

Dangers. (C. G.) Anginx malignx xtiologia, eique conveniens medendi meth-
odus. Goettengen, 1792.

Johnson. (Th.) Dissertation on the putrid ulcerous sore throat, 8vo. Philadel-
phia, 1793.

Rowley. (W.) Observations on the great number of deaths from sore throat, «^c.
8vo. London, 1793.

Withering. (W.) An account of the scarlet fever and sore throat. London,
1793.

Peart. (E.) Practical information on the malignant sore throat. London,
1802.

Nicaise. (P. F.) Considerations generates sur Vangine gangreneuse. Theses,
de Paris. 1806.

Pellissot. (F.) Diss. sur Vangine gangreneuse. Theses, de Paris. 1808.

Renauldin. Art. Angine. Diet, de Sc. Med. Paris, 1812.

Hosack. (David) Observations on croup, in American Med. and Philos. Regis-
ter, ii. 41. New York, 1812. The author confounds croup with diphtheritis.

Beneys. (J.) Diss. sur Vangine gangreneuse. Theses, de Paris. 1815.

Guersent. Art. Angine gangreneuse, in Diet, de Med. Paris, 1821.

Le Brun. (A. P.) Du croup et de ses rapports avec Vangine couenneuse pharyn-
gienne. Theses, de Paris. 1823.

Tabanon. (J. B.) Diss. et Obs, sur Vangine couenneuse, tonsillaire et pharyn-
gee. Theses, de Paris. 1824.

Andrews. (John) Remarks on the use of sanguinaria canadensis in cynanche
trachealis or croup, in the Med. Repository, N. S. viii. 239. New York, 1824.

Bibliography,

Gendron. (E.) Observations sur une angine couenneuse qui a regned'une man-
nitre epidemique dans It canton du Chateau-Renault, ^c. in Journ. Complem.
des Sc. Med. t. xxiii. p. 346. Paris, 1825.

Note sur V angine couenneuse et sur les agens therapeutique employes

dans cette maladie^ in the same Journal, xxx. 269. Paris, 1828.

Bricheteau. Precis analitique du croup de Vamgine couenneuse^ et du traite-
ment qui convient a ces deux maladies^ §f'c. Paris, 1826.

Bretonneau, (P.) Des inflammations speciales du tissu muqueuXy et enparticu-
Her de la diphtherite^ connue sous le nom de croup. Paris, 1826.

Ferband, (P. a.) De V angine membraneuse. Theses.de Paris. 1827.

Deslandes. Expose des progres et de Vetat actuel de la science sur cette question:
I’angine gangreneuse et le croup, consideres sous le rapport de Petat local qui
les constitue, sont ils identiquesl in Journ. des Progres des Sc. Med. i. 152.
Paris, 1827.

Fuchs. (C. H.) Historische Vhtersuchung ilber Angina maligna und ihr Per-
hdltniss, zu Scharlach und croup. Wurtzbourg. 1828.

Sachse. Art. Angina m Encycl. Worterb. Berlin, 1828.

Guimier. Memoire sur une epidemic d'angine maligne diphteritique^ qui a
regne a Vouvray et dans les communes voisines, a la fln de 1816 et dans le courant
de 1827. Journ. Gen. de Med. civ. 165. Paris, 1828. Note of M. Gen-
derin, p. 176.

Emangard. Memoire sur Pangine epidemique on diphterite, Annales de la
Med. Phys. Paris, 1829.

Boche. Art. Angine couenneuse, in Diet, de Med. Prat. Paris, 1829.

Lespine. Precis hlstorique de P epidemique d' angine maligne, plastique, gangre-
neuse (diphterite) qui a regne aPecole royale militaire de la Fleche, Archives Gen.
de Med. xxiii. 519. Paris, 1830.

Naumann. (M.) Ueher die Diphtheritis, in Decker’s Wissens-chaftliche anna-
len der gesammten Heilkunde. xxv. 271. Berlin, 1833.

Tweedie. Art. Throat, disease of, in Cyclop, of Pract. Med. iv. London,
1834.

Gendron. (E.) Propositions sur le croup et la tracheotomie, in Journal des
connaissances Med. Chirurg. Nov. 1835. Paris.

Ragueneau. Angine couenneuse on Diphtherite observee a Montfaucon, in Journ.
de Med. et de Chirurg. Pract. March. 1836. Paris.

The preceding Bibliography, though far from complete, is probably suffi-
ciently copious; it would transcend all proper limits, were it to embrace every
work that has appeared on the subject. There are a few papers, however, to
which we should have been pleased to refer, could we have obtained them or
their exact titles; and there are others which must be noticed in the Biblio-
graphies to the Monographs on Scarlatina and Croup, and need not be referred
to here. J. H.

BIOGRAPHY.

Art. XI. A Memoir on the Life and Character of Philip Syng PhysicJc,
M. D. By J. Randolppi, M. D.*

Gentlemen; — Permit me to express my sincere acknowledgments for
the honor you have conferred, in appointing me to prepare a Memoir of
the life and character of the long venerated President of this institution,
the late Doctor Physick.

I am quite sensible, that the selection was owing rather to my connec-
tion with the illustrious deceased, and the intimate relation which existed
between us for a long series of years, than to any peculiar ability 1 may
possess, of recording his many virtues and high qualifications. 1 am fully
aware also, of the weighty responsibility which that man assumes, who
undertakes to transmit to posterity a portrait, which, properly executed,
may serve as a light and example to illumine and instruct succeeding
ages. The effort to accomplish this object I consider, however, a duty
which I owe alike to you, and to the memory of Dr. Physick; and I shall
endeavour to discharge my obligations in the best manner consistent with
my means and abilities.

Most deeply must I deplore, at the commencement of my task, the want of
proper materials, which, faithfully recorded, would enable Dr. Physick’s
great and exalted character fully to develop itself. Many of you. Gentle-
men, cannot be ignorant, that the subject of our memoir throughout his
whole life, entertained a most invincible repugnance to appear before the
public in the shape of an Author; and this feeling induced him to exact the
promise that none of his manuscript lectures or letters should be pub-
lished.

The same modesty of feeling which he povssessed to an extraordinary
degree, and which forms a principal ingredient in the composition of a
truly great and noble mind, caused him also to refuse to comply with the
repeated requests made to him, to furnish sufficient facts upon which a
sketch of his biography might be founded. Upon one occasion, after ur-
gent solicitations he placed in my possession a few dates and incidents of
hjs life, with the permission to make use of them; excusing himself, how-
ever, from completing the materials at that time, upon the plea of his ill
health, and promising to furnish them at a subsequent period. His dis-
inclination to fulfil this promise was so obvious that I did not feel myself
justifiable in renewing the application.

*[This Memoir was read, in pursuance to appointment, before the Philadelphia Me-
dical Society, To bring- it within a compass which would render it more suitable to
the pagres of this Journal, the editor has, with the permission of the author, somewhat
abridged it. The curtailment, however, is principally in the language, the facts are
retained. Ed.]

Biography.

Philip Syng Physick was born in Philadelphia on the 7th of July, 1768*
His father, Mr. Edmund Physick, was an Englishman, and was character-
ised for possessing strong mental powers, with which were united strict
integrity and considerable knowledge of the world. Previously to the
separation of the United States from Great Britain, he held the office of
Keeper of the Great Seal of the Colony of Pennsylvania; and subsequently
to the Revolution he took charge of the estates belonging to the Penn
family, and served as their confidential agent. Doctor Physick’s mother
was a most estimable, pious woman, who was blessed with a strong intel-
lect, and evinced throughout her life, great judgment and decision of cha-
racter. The Doctor never ceased to feel and express, the greatest filial
love and reverence for these honoured parents. He frequently declared,
that he was convinced that whatever was most useful and excellent in his
character, was attributable to the early lessons and impressions which he
imbibed from thejm.

By such parents as these the greatest care and attention would naturally
be bestowed upon the education of their children. Fortunately his father
had succeeded by great industry and attention to business, in accumulating
a property which, in those days, was looked upon as considerable; and
being thus in possession of ample means, he was enabled to carry out fully
the plan of education which he designed for his son.

In doing so Dr. Physick informed me that his father was influenced by
a degree of liberality very unusual in that, or indeed in any age. Double
fees which he uniformly transmitted to the teacher testified the great im-
portance which he attached to a liberal education, and the value which he
thought should be set upon the sources from which it emanated. This was
not only intended for an encouragement to the instructor to use his best
endeavours on behalf of his pupil, but because the donor believed the
charges for tuition at that day were not a fair equivalent for the services
rendered.

Mr. Physick placed his son, when eleven years of age, in the academy
belonging to the Society of Friends, in south Fourth street, under the
tuition of Robert Proud. At this period Mr. Physick resided in the
country, on the banks of the Schuylkill, several miles from the city,
at an estate belonging to the Penn family. To facilitate the education
of his son, he boarded him in the city, in the family of the late Mr. John
Todd, the father-in-law of the present venerable Mrs. Madison. Even at
that early age the subject of our memoir exhibited strong indications of
those well regulated habits of order and method which adhered to him so
closely throughout his life. Every Saturday after school broke up, he was
allowed to go to his father’s residence in the country, where he remained
until the following Monday morning. He then not unfrequently was
obliged to walk into town, and sometimes through most inclement weather.
Notwithstanding this, he always presented himself at school exactly o.t the
time of its opening. His teacher was so much gratified with this extra-
ordinary punctuality, that he took pleasure in holding him up as an exam-
ple to other boys, who, though living in the vicinity of the school, were
too apt to be remiss in making their appearance at the proper hour.

Young Mr. Physick remained at this academy until he entered the col-
legiate department of the University of Pennsylvania. He then passed
through the usual course of studies prescribed in that institution, and took

Memoir of Dr, Phydck,

the degree of Bachelor of Arts in May, 1785. I am not aware that any
thing remarkable occurred during the period of his collegiate studies. —
That he was a diligent and exemplary student cannot for a moment be
questioned. It is well known that he was particularly successful in ac-
quiring a thorough and intimate knowledge of the classics, of which he
retained sufficient, amid all his engagements, to be able to translate them
with facility, to the time of his death.

In June, 1785, he commenced the study of medicine, under the superin-
tendence of the late Dr. Adam Kuhn, well known as the pupil of Linnaeus,
and a most distinguished and successful practitioner, and then Professor of
the Theory and Practice of Medicine in the University of Pennsylvania.
Of the particular motives which influenced young Mr. Physick in the
choice of this profession I am unable to speak. It does not appear that he
at that period evinced any strong predilection for this department of sci-
ence. Probably he was in a great degree governed by the wishes of his
father; and so strong were his feelings of filial obedience that I am very
certain that he would at any time readily have yielded his own wishes to
those of his parents. The following anecdote is traditionary in the family.
His father, whilst handling a knife, had the misfortune to cut one of his
fingers; and the wound proved to be so severe that he was obliged to en-
gage the services of a medical friend. Upon one occasion his son begged
of him to he permitted to apply the necessary dressings and bandage to the
finger: his father consented, and was so much surprised at the great skill
and dexterity which his son displayed in making the applications, that he
determined to make him a surgeon.

If it be true that we are indebted so exclusively to Mr. Physick for di-
recting his son’s attention to the study of medicine, to what an immea-
surable extent does it not increase the amount of obligation and gratitude
that we owe to him?

Dr. Physick was remarkable through life for feelings of the most acute
and susceptible nature. It may be truly said of him that he possessed a
soul feelingly alive to the miseries and sufferings of others. He could not
himself support pain with an ordinary degree of fortitude, and it is
undeniable, that he was extremely unwilling to inflict it upon others.
This tenderness of feeling, which existed strongly in the days of his
youth, continued in full force as long as he lived, as I shall have
occasion to show during the progress of this memoir. He used fre-
quently to declare at this period of his life, that he never could be a sur-
geon. Little was he aware, that he was destined to afford a complete
illustration of the position, that the practice of medicine and surgery, so
far from hardening and rendering callous the feelings, has a direct contra-
ry tendency, and serves pre-eminently to soften and refine them. His ex-
ample, as well as the result of our whole experience upon this subject, de-
monstrates that for a man to become a great and good surgeon, it is abso-
lutely necessary for him to possess to the fullest extent, the best and kind-
est feelings of our nature.

The following incident, which occurred to Dr. Physick, and which was
in fact characteristic, may not be deemed uninteresting. Soon after he
commenced the study of medicine, it was announced that an amputation
would be performed upon a certain day, at the Pennsylvania Hospitah —
His preceptor. Professor Kuhn, wished him to witness this operation, but

Biography,

understanding perfectly well the peculiar temperament of his pupil, he ad-
vised his father to accompany him; and fortunately too, inasmuch as Dr.
Physick became so sick during the operation that it was necessary that he
should be led from the amphitheatre before it was concluded.

Dr. Physick continued his medical studies under the superintendence of
Professor Kuhn, for three years. In those days it was customary for the
student of medicine, previously to obtaining the honours of the doctorate,
to go through a much more extensive course of reading than is now
deemed necessary. By the direction of his preceptor. Dr. Physick read
through most diligently and faithfully, many voluminous works of the
older medical writers, some of which, if not absolutely obsolete at the
present day, are only used as works of reference. We have abundance
of evidence, that even at that early period of his life, Dr. Physick evinc-
ed the most resolute determination to qualify himself by every possible
means, for assuming a most useful and honourable standing in his pro-
fession: and there cannot be a question but that he must have gleaned
from amidst this great mass of laborious reading, much valuable informa-
tion, which he subsequently applied to an excellent purpose.

Dr. Physick’s whole deportment during his pupilage, was so perfectly
correct and satisfactory, as to merit the entire approbation of Professor
Kuhn: and it is well known, that Dr. Physick always cherished feelings
of the warmest affection and regard for his venerable preceptor.

In addition to the instruction which Dr. Physick received from Professor
Kuhn, he attended at this period the medical lectures delivered in the
University of Pennsylvania. He did not, however, graduate in medicine
in that institution. The opportunities for the acquisition of medical know-
ledge offered by the schools and hospitals of this country, then in its in-
fancy, were too limited to satisfy either his conscience or his ambition.
He could not convince his mind that his knowledge of medicine was suffi-
ciently enlarged to warrant him in assuming the deep and important re-
sponsibilities attendant upon the practice of a profession which involved
the lives and happiness of his fellow creatures. For the completion of
his education, he entertained an ardent desire to visit Great Britain-, and
to avail himself of the advantages which were afforded by the great
schools and hospitals of London and Edinburgh. His father happily
coincided with these views, and determined upon accompanying his son
to Europe. Accordingly they embarked in November, 1788, and arrived
in London in Jannary, 1789.

Dr. Physick’s sole object in going abroad was to acquire medical in-
formation. He had no desire to partake of the gaieties and amusements
of an European capital. I repeat, with him the grand consideration was
the acquisition of knowledge: to this he applied himself with the most
ardent devotion, and never permitted aUiUsements of any kind to turn
him aside from its pursuit.

Fortunately for Dr. Physjck, his father’s connections in London were
such, that he was enabled to introduce his son to some of the most learn-
ed and polished society, of that great metropolis. An intercourse of this
kind created for him an influence and gave him opportunities by means
of which his cherished views were considerably promoted. All who ever
saw Dr. Physick must have been struck with the exceeding dignity and
courteousness of his manner. For this no doubt he was principally in-

Memoir of Dr. Physick*

“^.ebted to nature, though it must have been improved and confirmed by
jis association with the elevated society which he enjoyed whilst abroad.
i5y means of this same influence Mr. Physick succeeded in securing the
consent of Mr. John Hunter, then one of the most celebrated anatomists
and surgeons of the age, to receive the subject of our memoir under his
immediate care and tuition.

Dr. Physick considered this as the most important era in his profes-
sional life. He early became convinced of the extraordinary advantages
which he might derive from this connection with Mr. Hunter, and pro-
ceeded accordingly to devote himself with the most ardent zeal to the
study of practical anatomy and surgery. By dint of constant and unwea-
ried application to his studies, aided also by a course of unceasing and
untiring dissections, he soon made rapid advancement it] the attainment
of his objects, and what was also of mucli consequence, secured to him-
self the approbation and esteem of his great master. Mr. Hunter, in
fact, was so well pleased with the zeal, industry, and correct deportment,
of Dr. Physick, that he took pleasure in acknowledging him as a favouiite
pupil, and bestowed upon him, with the most unreserved confidence, the
full benefit of his advice and experience. During this period Dr. Physick
attended regularly the lectures delivered by Mr. John Clark and Dr. Wm.
Osborne on Midwifery..

Among the manuscript papers left by Dr. Physick which have fallen
into my possession, is a note book, kept by him during his stay in England,
in which he recorded such facts and incidents as came under bis observa-
tion, w^hich he supposed might be of service to him subsequently. I take
the liberty of making two or three extracts from these notes, in order to
exemplify the careful manner in which he perform.ed this duty, and the
pains which he took to treasure up all the information which he gained.

February, 1789.— Visited Mr. Hunter. In the evening, after being enter-
tained with tea, coffee, and general conversation. Doctor Baillie exhibited a pre-
paration ” [He then goes on to describe the preparation; which, although ex-
ceedingly interesting to the medical profession, it would not be proper to insert
here.]

“ February, 178.9. — Mr. Home performed an operation on a sheep which had
the staggers, in the following manner. After making a crucial incision through
the integuments of the cranium, he applied the trephine, and removed a portion
of the bone from the upper and middle part of the cranium. When this was
done, he introduced a pair of small forceps, with which he extracted a tasnia
hydatigena. The effect was, that the sheep, being set at liberty, stood on its
legs, which before it could not do. This, however, was only a temporary
amendment, as it died about twenty hours after the operation was performed.”

^'‘November 15, 1789. — Mr. Cruickshank related the particulars of a case of
hydrothorax, in which, upon opening into the right side of the chest, he evacu-
ated nine pints of water, and in the left side there was found one pint. The
lung of the right side was compressed to a small size, and instead of feeling
spongy as common, it was solid and fleshy, and quite incapable of being dilated
by air, so that the respiration was carried on by the left lung altogether. The
patient, during his life, was incapable of sitting or standing up, feeling great
pain when he attempted it; but was quite easy in bed when lying on his right
side, but could not lie on his left side. His pulse, for near two months before
his death, was quite regular, though before that time it had been otherwise, and
the apothecary who had attended him had suspicions of hydrothorax. There
was a swelling in the abdomen, which was very painful to him. This proved
No. XLVIl.— May, 1839. 9

Biography,

to be a cancerous tumour of the whole of the omentum, which, being very heavy,
when he attempted to get up gave him the pain mentioned before.”

“ Mr. Cruickshank said that he saw a case of hydrothorax where there was
no pulsation to be felt, either in the carotids, or in the arteries at the wrists, or
in the groin, nor could any motion be perceived at the part where the heart is
usually felt pulsating; and the patient continued in this state for two months.”

Dr. Physick continued to prosecute his studies with the most exemplary
perseverance and industry, under the immediate superintendance of Mr.
Hunter, throughout the year 1789. On the first of January. 1790, he was
appointed House Surgeon to St. George’s Hospital for one year, the usual
period of that service in the institution. 'Phis appointment he owed ex-
clusively to the patronage and influence of Mr Hunter. The advantages
of such a situation to the student of medicine, in facilitating his acquisi-
tion of practical knowledge and skill, were of the most important charac-
ter; and were so well known as to cause the place to be sought after by
numerous applicants, most of whom, from the circumstance of their Eng-
lish birth alone, it might be supposed, could have had an influence which
would have rendered them successful competitors against a foreigner for
the place. Here were exemplified in the most happy manner, the impor-
tant advantages which Dr. Physick derived from the favourable impres-
sions which Mr. Hunter had imbibed respecting his general worth, his
talents, and his acquirements. These considerations induced Mr. Hunter
unhesitatingly to exert the whole of his influence in behalf of Dr. Physick,
with what eflect has been stated.

A few months after this period, Dr. Physick had so severe an indisposi-
tion, that Mr. Hunter became alarmed about him, and was on the eve of
insisting upon his return to America. This attack, no doubt, was princi-
pally owing to the laborious life which he led. and the close confinement to
which he subjected himself. Providence, however, for its own wise and
beneficent purposes, thought proper to restore him to health, to the great
delight and gratitude of his parents and friends.

It was during the period of his remaining at St. George’s Hospital, that
Dr. Physick acquired a vast deal of that surgical skill and dexterity which
laid the foundation of his subsequent greatness. Having his whole time
occupied in administering to the wants of such unhappy objects as were
suffering from the effects of accidents or disea'^e; being constantly engaged
in applying the necessary bandages and dressings to fractured bones, dislo-
cations, wounds, and injuries of every description, and seizing hold, as was
his invariable custom, of every such opportunity of making himself mi-
nutely acquainted with the most perfect manner of performing these
services, he soon became remarkably expert in all his manipulations, and
acquired a degree of experience which increased greatly his stock of prac-
tical knowledge. He indeed exhibited a degree of neatness and dexterity
in the application of bandages and dressings never excelled probably by
any other surgeon.

During the period of his services in this institution, he learned also the
manner of constructing and contriving several kinds of instruments and
apparatus, which he subsequently was the first to introduce into this coun-
try, to the great benefit of our art.

An anecdote frequently related to me by Dr. Physick, connected with
his early appointment to St. George’s Hospital, I may be pardoned for
mentioning here, notwithstanding it has already been promulgated from

Memoir of Dr, Physick,

another source. His success in obtaining this situation caused some slight
degree of dissatisfaction on the part of some of the disappointed applicants,
who conceived that their claims for the situation were stronger than his.
In consequence of this, Dr. Physick perceived that they evinced uncom-
mon curiosity respecting his manner of discharging his duties, and were
disposed to scrutinise his actions with the greatest strictness. A short
period after commencing his services, a patient was admitted into the hos-
pital with dislocation of his shoulder; the head of the humerus being lodged
in the axilla. Fortunately the accident was quite recent. It so happened
that at the time the man was admitted, the whole class were in attendance
at the house. They, of course, were exceedingly anxious to witness the
manner in which the reduction would be etFected, and Dr. Physick was well
aware that his method of restoring the bone to its natural situation would
be severely criticised. He directed the patient to be seated upon a high
chair, and then proceeded to examine the injured shoulder, questioning the
man as to the manner in which the accident had occurred. Whilst making
these inquiries, he placed his left hand in the axilla, and taking hold of the
lower end of the humerus with his right hand, he made all the extension
in his power, then suddenly depressing the elbow of the patient, he dis-
lodged the head of the bone, which glided instantaneously into the glenoid
cavity.

In relating this incident, Dr. Physick never assumed to himself much
merit for his success, but rather ascribed it, in a great degree at least, to
the favourable nature of the case. His characteristic modesty, however,
induced him to Underrate his services; his success was doubtless principally
owing to that unrivalled address and dexterity of which he subsequently
proved himself to be so complete a master. The treatment of this case
produced the most happy influence in promoting the interest and comfort
of the doctor during the remainder of his stay in the hospital. He stated
that from that time forward he always enjoyed the uninterrupted regard
and respect of the medical class.

In January, 1791, the period for which he had been elected to St.
George’s Hospital having expired, he quitted the institution, carrying with
him the warmest testimonials, from its proper authorities, of his medical
qualifications, and also of his general good conduct. They went so far as
to declare, that instead of considering him to lie under any obligations to
the institution, they considered the institution indebted to him for the many
benefits he had conferred upon its unhappy inmates, and for the useful re-
sults which had been produced by his singular zeal and abilities. He now
received his diploma from the Royal College of Surgeons in London.

Soon after leaving St. George’s Hospital, Dr. Physick received from Mr.
Hunter a mark of respect and esteem, which was in the highest degree
gratifyinir to him, and more particularly so as it furnished conclusive evi-
dence of Mr. Hunter’s entire confidence in his professional skill and attain-
ments. Mr. Hunter invited him to take up his residence v/ith him, to be-
come an inmate of his house, and to assist him in his professional business;
he also held out inducements to him to establish himself permanently in
London.

Notwithstanding the tempting nature of these offers, and the great ad-
vantages which Dr. Physick might have derived from accepting them, it
did not comport with either his own designs, or those of his father, that he

100

Biography,

should exile himself from his native country. In accordance with the plan
previously laid down for the completion of his medical education, he was
to visit Edinburgh, in order to graduate in medicine in the University of
that city. He, however, gratefully accepted Mr. Hunter’s invitation to re-
side with him until this period should arrive; and accordingly he remained
with Mr. Hunter, and assisted him, not only in his professional business,
but also in the prosecution of his physiological experiments, and the making
of anatomical preparations, until May, 1791, when he took his final leave
of London, I may notice that his father had, previously to this period,
returned to America.

The parting between Mr. Hunter and Dr. Physick was painful to the
latter to an extreme degree, and certainly the most distressing event which
occurred to him during his stay in London. The ties which bound him
to Mr. Hunter were of no ordinary description. Mr. Hunter had not only
extended towards him the warmest friendship and regard, but had also
conferred invaluable benefits upon him, by giving him the advantages of
his powerful aid and influence, and by promoting, by all the means in his
power, his medical researches.^ These obligations could only be acknow-
ledged on the part of Dr. Physick, by the most sincere and ardent devo-
tion to his beloved preceptor; and in fact the admiration felt for Mr. John
Hunter by Dr. Physick amounted to a species of veneration; he never
ceased to consider him as the greatest man that ever adorned the medical
profession. Could his honoured master have been permitted to witness
the closing career of his pupil, he would have felt himself amply recom-
pensed by the rich harvest of fame and usefulness which the latter had
gathered, in consequence of his valuable aid and instructions.

Immediately after his arrival in Edinburgh, Dr. Physick entered with
his usual ardour upon the prosecution of his studies. He attended very
diligently the medical lectures delivered in the University, visited con-
stantly the Royal Infirmary, was a careful observer of the practice pur-
sued in that institution, and witnessed all the operations there performed.
In May, 1792, having complied with all the requisitions demanded by the
University, he obtained the degree of M. D. The subject of his thesis
was apoplexy; and in compliance with the established regulations it was
written in the Latin language. The original manuscript of this essay,
which he first wrote in English, is now in my possession, and bears the
most satisfactory evidence of having been prepared with a vast deal of
careful attention.

To show the familiar knowledge of the Latin language which Dr.
Physick possessed, I may relate the following anecdote. It is well known
that the examinations for a medical degree in Edinburgh are conducted
in Latin; and that there are many applicants for the honour who from
not possessing a sufficient knowledge of that language are compelled to
have recourse to the aid of a class of men termed grinders, whose occu-
pation consisted in preparing students, by a system of drilling which
should render them competent to reply to such questions as were likely to
be put to them. It so happened that, a short time previous to the exami-
nations^ Dr. Physick was in company with a fellow-student frotn this city,
and in reply to some allusion made by his companion to these grinders,
the Doctor stated that he should not seek their aid, but that he was de-
termined to rely upon his own knowledge of the language to carry him

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Memoir of Dr, Phydck.

safely through. His companion expressed much surprise at this state-
ment, seeming to c msider it as a vain boast on the part of Dr. Physick;
and he intimated his doubts of the Doctor’s capabilities, inquiring whe-
ther he meant to say that he possessed a sufficient knowledge of the Latin
to enable him to carry on a conversation in that language. Dr. Physick
satisfied him completely, by instantly addressing him in Latin, and con-
tinuing for some time to converse with him in that tongue.

Dr. Physick did not leave Edinburgh immediately after obtaining his
honorary title: he remained there for a short period; and the manner in
which he occupied himself may be fairly illustrated by the following ex-
tract from his note book.

“ June, 1792. — Prepared for the house surgeon at the Royal Infirmary, Edin-
burgh, an intussusceptio, in which the ileum had passed into the colon, and at
last dragged down six inches of the colon. Most probably there was a stric-
ture formed about the termination of the ileum, near the valve, as there were
strictures in other parts of the intestines. At present a stricture of the ileum at
this part certainly exists, but whether that did not arise from the binding of the
inverted colon, and the inflammation consequent thereon, I cannot be sure. I
was not present at the dissection of the body, and the person who took out the
parts tore them very much.”

Dr. Physick returned to his native country in September, 1792; and
commenced the practice of his profession in Philadelphia. His office was
situated in Mulberry Street near Third. 'Fhat Dr. Physick entered upon
his practical career under the most favourable circumstances will, I think,
be readily admitted. I have already shown that, in addition to his own
extraordinary qualifications, he had enjoyed the most ample opportunities
of acquiring knowledge from sources distinguished alike for their exalted
character and superior excellence. Nature also rendered her best aid for
fitting him pre-eminently, by all external advantages, for the successful
accomplishment of his objects. His personal appearance was command-
mg in the extreme. He was of a medium height; his countenance was
noble and expressive; he had a large Roman nose; a mouth beautifully
formed, the lips somewhat thin; a high forehead, and a fine penetrating
hazel eye. The expression of his countenance was grave and dignified,
yet often inclined to melancholy, more especially when he was engaged in
deep thought, or in performing an important and critical operation. Dr.
Physick rarely indulged in excessive mirth; he was, however, far from
being insensible to playful humour, and on such occasions his countenance
would be lighted up by a benign smile, which altered entirely the whole
expression of his features. II is manners and address were exceedingly
dignified, yet polished and affable in the extreme; and when he was en-
gaged in attendance upon a critical case, or in a surgical operation, there
was a degree of tenderness, and at the same time a confidence, in his
manner, which could not fail to soothe the feelings and allay the fears of the
most timid and sensitive.

The introduction of a young practitioner of medicine to the notice of
the community, is proverbially slow; and not unfrequently, before be can-
inspire a sufficient degree of confidence to lead to bis employment, a
length of time is requisite which, in some instances, produces bitter dis-
appointment, and occasionally even utter hopelessness and despair. As
might have been anticipated, there were but few professional calls made

102

Biography*

upon Dr. Physick during the period of the first year after he had estab-
lished himself in this city; and it is highly probable that, notwithstanding
all the advantages of which he could boast, he would have been obliged to
exercise an enduring degree of patience for a considerably longer period,
were it not that in the summer of 1793, Philadelphia had the misfortune
to be visited with that awful calamity, the yellow fever. It is not neces-
sary in this place to give an account of the destructive ravages caused by
this epidemic. The most ample and detailed description of its origin and
progress, with all its concomitant circumstances, has been furnished by
one of the brightest luminaries of the age; one who was a most promi-
nent and efficient actor in the tragical scene; whose disinterested patriot-
ism, brilliant imagination and splendid acquirements endeared him to the
hearts of his countrymen, and who invariably evinced himself to be
the warm friend of Dr. Physick. Need 1 add the name of Dr. Beniamin
Rush?

The occurrence of the yellow fever afforded to Dr. Physick his first op-
portunity of proving to his fellow citizens his entire devotion to his profes-
sional pursuits, his utter disregard of all personal considerations which
might interfere with the discharge of his duties, and the fearless intrepi-
dity with which he exposed himself to danger, in order to contribute to
the safety of others. As a means of preventing an extension of the dis-
order by removing, as far as possible, from overcrowded situations those
who were attacked by it, and also to afford an asylum and the most efficient
treatment to such as were destitute, the Board of Health, in August, 1793,
established the yellow fever hospital at Bush Hill, and Dr. Physick, having
offered his services, was elected by them physician to the institu ion. He
immediately proceeded to the performance of his duties with singular
ardour and ability; and during the time he remained in the hospital, ren-
dered services which were acknowledged to be of the most important
character, and which served to secure to him the approbation and esteem
of the coh.munity at large. Dr. Physick himself did not escape an attack
of the fever. It however yielded to treatment, although I heard him de-
clare, but a short time previous to his death, that he did not think his con-
stitution had ever completely recovered from the shock which it then
received.

During a period of such general distress, history has at all times shown
that the minds of the people are very apt to become excited and inflamed;
and some threatening indications of riotous conduct having been exhibited
whilst Dr. Physick was serving in the Bush Hill hospital, he was created
an Alderman by the Governor of the State of Pennsylvania, for the pur-
pose of enabling him to quell disturbances.

The publicity which Dr. Physick obtained, together wdth the favourable
impression which he produced during his residence in the hospital, led to
acquaintances which subsequently assisted in promoting his professional
success. Among others, whose lasting friendship he then secured, was
that of our late fellow citizen, Stephen Girard, at that melancholy epoch a
member of the Board of Health, and who rendered the most important
services throughout the epidemic, in alleviating the miseries and providing
for the wants of the unhappy sufferers; services which should never be
fora’otten.

Mr. Girard was well known to have been a man of very eccentric habits

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Memoir of Dr. Physick.

and strong prejudices. One of his peculiarities consisted in a general dis-
like of physicians; a prejudice founded upon his ignorance, and a vain be-
lief that he knew as well from his own experience how to treat diseases, as
most men who were regularly educated to the profession. He, however,
made a few exceptions; and one of these was Dr. Physick, to whom, as
long as he lived, he resorted for medical advice and assistance, whenever
he deemed the case critical. Mr. Girard finally died a victim to his pre-
judices: he was attacked with an inflammation of his chest, and would not
consent to lose blood until too late.

Dr. Physick, I believe, was the first to promulgate the doctrine, founded
upon his own observations, that the yellow fever was not cont.tgious; he
also fully coincided with Dr. Rush in the opinion that it was of domestic
origin. Dr. Rush at first dissented from the doctrine of the non-contagious
character of yellow fever, but subsequently became convinced of its truth
and importance. During the prevalence of the epidemic. Dr. Physick, in
conjunction with Dr. Cathrall, made a series of post niortem examinations,
which went far, not only to elucidate the true nature of the disorder, but
also to indicate the best method of treatment. These dissections proved
satisfactorily that the complaint was of a highly inflammatory character,
that the stomach more particularly was the seat of great inflammation, and
consequently confirmed the propriety of the antiphlogistic method of treat-
ment instead of that of an opposite character, which had generally been
employed. Thus Dr. Physick preceded the celebrated Broussais in point-
ing out the intimate relations which subsist between the condition of the
stomach and the production of bilious and yellow fevers. It is well known,
that as far back as the period to which we are alluding. Dr. Physick pro-
nounced yellow fever to be gastritis; and he was so much influenced by
his opinions of the necessity of avoiding all causes which could prolong or
excite the gastric irritation that in one instance he ascribed the death of a
patient labouring under this malady, to a relapse produced by swallowing
a small quantity of chicken water.

After leaving the hospital he removed to the city and gave his undi-
vided attention to his prolessionul engagements. In the year 1794, Dr.
Physick was elected, by the managers of the Pennsylvania Hospital, one
of the surgeons to that institution. This period was the dawn of his great
surgical fame and usefulness. The reputation sustained by the Pennsyl-
vania Hospital for a long series of years, not only for the amount of bene-
fits which it has conferred, but also on account of its excellent administra-
tion, are so well known as to render superfluous any encomiastic notice of
it on my part. 4’hat Dr. Physick contributed largely to the support of its
character and reputation, can be readily shown by a record of his services.
It must be admitted, however, that his appointment to the hospital had a
considerable influence in promoting his success, and leading to an exten-
sion of his business. 'Fhe situation enabled him to add greatly to his
stock of experience, and aflbrded him ample opportunities of perfecting
himself in the operative department of his profession. I have already
stated that in his manual procedures he exhibited the utmost degree of
neatness and dexterity. Dr. Physick possessed pre-eminently all the
qualifications requisite for a bold and successful operator. His sight was
remarkably good; his nerves, when braced tor an operation, were firm
and immovable; his judgment was clear and comprehensive, and his re-

104

Biography.

solutions once formed, were rarely swerved from. In addition to these
he owed much to his thoughtful and contemplative cast of character,
which induced him to deliberate and reflect intensely upon all the circum-
stances of his case, and to make elaborately beforehand every preparation
w^hich might become needful in the performance of his task.

In order to appreciate fully and correctly the amount of contribution,
made by Dr. Physick to the department of surgery, it is important to
call to mind the imperfect condition of the art in this country, at the pe-
riod of his commencing his professional career. It is well known that
the principles of science which should govern the treatment of many dis-
orders were at that day very imperfectly understood. It is true that there
were some members of the profession, possessed of great merits and
learning, who devoted themselves especially to the cultivation of surgery.
These gentlemen were quite competent fo the performance of what were
then considered the capital operations in surgery; still it must be confess-
ed that none of them ever acquired the necessary degree of skill and
pre-eminence to create an unlimited confidence in his abilities. In conse-
quence of this there was no head, no rallying point in surgery, an appeal
to which, when once made, would be regarded as decisive. We cannot
feel surprised at the comparatively insignificant position which the science
of surgery then held, when we reflect that, prior to the appointment of
Dr. Physick, surgery was not taught in this city as a separate and dis-
tinct department. The professorships of anatomy and surgery were com-
bined in the University of Pennsylvania, and the duty of teaching both
branches devolved upon one individual. Under these circumstances it
would have been extremely unreasonable to expect an efficient course of
instruction when it is well known that the usual period allotted to a course
of lectures upon either department, as now separated, is confessedly too
limited.

Soon after Dr. Physick’s appointment to the Pennsylvania Hospital, his
mind became engaged in the consideration of a class of disorders of which
that institution then had, and continues to have its full proportion, namely,
ulcers. The treatment of these affections was at that day but little under-
stood by our surgeons, and was for the most part exclusively empirical;
consequently it was notoriously unsuccessful; and I am sorry to say, that
there are good reasons for believing that limbs, affected with ulcers were
not unfrequently amputated, which, by a judicious and skilful treatment,
might have been preserved.

Dr. Physick devoted himself in an especial manner to ameliorating the
condition of this class of patients, by establishing a more correct and effi-
cient method of treatment; and in a short time the success of his practice
was so evident as to add not a little to his rising fame and greatness. I
have been told thatat a very limited period after commencing his services,
he had almost entirely cleared the wards of patients affected wdth ulcers.
His method of treatment in cases of inflamed and irritable ulcers was ex-
ceedingly simple. He directed the patient to be confined to bed, enjoin-
ed rest; and where the ulcer was situated upon a lower extremity, he
caused the limb to be considerably elevated. He next directed mild and
soothing applications to be made to the ulcer itself; and in conjunction
with this he made use of proper constitutional treatment. Where the
ulcer partook of an indolent nature, he always preferred effecting the ne-

Memoir of Dr, Physick,

105

cessary stimulation by means of local applications, whilst the patient was
confined to bed, to permitting him to walk about, as sometimes recom-
mended.

Dr. Physick, during the period of his services in the Pennsylvania Hos-
pital, made several valuable improvements in the treatment of frac-
tures. Without entering minutely info the consideration of these, 1 may
refer to his modification of Desault’s apparatus for the treatment of frac-
tures of the thigh. By increasing the length of Desault’s splint. Dr.
Physick accomplished a most important object, causing the counter-ex-
tension to be made more nearly in the direction of the axis of the limb,
and also in keeping the patient more strictly at rest. This apparatus of
Desault, thus modified by Dr. Physick, and with the block attached to
the lower extremity of the splint by Dr. Hutchinson, for the purpose of
making the extension in the direction of the limb, has been used in the
Hospital for a long series of years, with the happiest results. Dr. Phy-
sick never ceased to regard it as the most complete and successful method
of treating fractures of the thigh.

Fractures of the humerus occurring at or near the condyles, are ex-
ceedingly apt to be followed by a projection of the elbow. In some
instances the deformity is so great as to give rise to most disagreeable
consequences, more especially where the accident happens to a young
female. To Dr. Physick is due the credit of having invented a method
of treatment which has succeeded in many instances in effecting a com-
plete cure, without the occurrence of any deformity. This treatment con-
sists in applying to the injured limb two angular splints, which should ex-
tend from near the shoulder down to the extremities of the fingers. In
addition to this he directs the patient to be kept in bed, “ with the arm
flexed ai the elbow, and lying on its outside with the angular splints, sup-
ported by a pillow.”

In cases of fracture of the lower end of the fibula, where the accident
is accompanied with dislocation of the foot outward, Dr. Physick was in
the habit, many years since, of treating the fracture upon a plan precisely
similar lo that recommended by Baron Dupuylren. To which of these
gentlemen is due the priority of the invention, I am unable to say.

In the treatment of dislocations, the highest commendation is due to Dr.
Physick, for being the first to carry into full effect a plan of treatment
which, although originally suggested by Doctor Alexander Munro, of
Edinburgh, was never put into execution, so far as I can learn, prior to
its employment ^by Dr. Physick. I allude to the use of copious blood-
letting, carried, when necessary, even ad deliquium animi, in order to pro-
duce a complete relaxation of the muscular system, and thereby facilitate
the reduction of the dislocated bone. By this method of treatment, in
very many instances, old and difficult dislocations have been reduced, which
otherwise would have been irremediable, and limbs thus restored to use-
fulness.

In the year 1794, Dr. Physick Was elected one of the physicians to the
Philadelphia Dispensary; and during the period he held this appointment,
he performed his duties with the strictest fidelity. He subsequently was
appointed one of the consulting surgeons to this institution, and retained
the situation till the time of his death.

From a reference to Dr. Physick’s papers, it appears, that his profes-

106

Biography,

sional engagements increased very considerably in the year 1795. About
this period, his prospects of establishing himself in practice became ex-
ceedingly flattering. During the year 1795, he commenced keeping a
journal of the most remarkable and interesting cases which occurred in his
practice, more especially those of a surgical character. This journal is
continued up to the year 1810, although in consequence of the multiplicity
of his engagements about this period, we have to regret, the number of
cases inserted is very considerably lessened. The first case recorded in
the note book, is that of a lady affected with blindness from cataract. In
this case, he performed the operation of extraction of the opaque crystal-
line lens, with complete success, and restored his patient to sight.

I may mention here that Dr. Physick’s favourite operation for cataract
was that of extraction, and he always performed it whenever the condition
of the eye was suitable. He acquired such a perfect degree of skill in
extracting the lens, that his operations were almost invariably followed by
success. I am of opinion that his operations upon the eye, in conjunction
with those for stone in the bladder, did as much in establishing his great
surgical character as any others which he performed. Operations of this
nature, when successfully executed, in that day, were widely known. His
first operation of lithotomy was not performed, however, until the year 1797.
He subsequently performed it, as is well known, in numerous instances,
with extraordinary facility and success. In performing his first operation
of lithotomy, he accidentally divided wdth his gorget the internal pudic
artery. The hemorrhage from the wounded vessel was exceedingly pro-
fuse. He immediately compressed the trunk of the artery with the fore
finger of his left hand, next passed the point of a tenaculum under it, and
a ligature was then cast round it and firmly tied. This of course arrested
the hemorrhage, but the ligature included along with the artery a consid-
erable portion of the adjacent flesh. To obviate this inconvenience Dr.
Physick subsequently contrived his celebrated forceps and needle, for car-
rying a ligature under the pudic artery. Since that period this instrument
has been in general use for securing deep seated vessels. It has twice
been successfully employed in the operation of tying the external iliac ar-
tery; in the first instance by the late lamented Doctor Dorsey, a favourite
nephew of Dr. Physick’s and one to whom he was ardently attached, and
in the second instance by myself. No higher commendation could be be-
stowed upon this instrument than may be inferred from the numerous modi-
fications which have since been made of it. I must be permitted to de-
clare, that in my opinion, the original instrument, as designed by Dr. Phy-
sick, has never been excelled, either in point of ingenuity or utility.

To facilitate the division of the prostate gland and neck of the bladder,
in the operation of lithotomy by means of the gorget, Dr. Physick sug-
gested a valuable improvement to the instrument as used by Mr. Cline,
which has since been almost universally adopted in this country, and has
received the entire sanction and approbation of our most distinguished sur-
geons. A full description of Dr. Physick’s gorget was published in the
year 1804, in Coxe’s “Medical Museum.” The modification consists in
, having the gorget so constructed, that a perfectly keen edge may be given
to that part of the blade which commences the incision, and which is con-
nected to the beak of the instrument. For this purpose the beak and
blade are separable, and so arranged that the blade may be connected to

Memoir of Dr* Physick,

107

the stem and firmly secured by a screw. Without this arrangement it is
exceedingly difficult to impart a fine edge to that part of the blade which
is contiguous to the beak, and inasmuch as the incision of the neck of the
bladder is commenced at that point, the success of the operation must
necessarily be much influenced by it.

During Dr. Physick’s attendance at the Pennsylvania Hospital, in the
year 1796, a case occurred in which the patient, a young man, had labour-
ed under a suppression of urine for forty-eight hours. The bladder was
so much distended that it rose above the umbilicus, and the patient was
suffering intense agony. Dr. Physick made repeated attempts to intro-
duce catheters of diflerent sizes into the bladder, in order to draw off the
urine, but without success. He next took a bougie and succeeded in in-
troducing it into the bladder, but upon withdrawing the instrument, no
urine followed. The idea then struck him that he might fasten the point
of a bougie upon the extremity of an elastic catheter, so as to conduct the
catheter into the bladder and allow the urine to flow through it. He im-
mediately carried his plan into execution, and succeeded most happily in
completely relieving his patient. Since then this method has been fre-
quently resorted to with great success, in cases where, owing to enlarge-
ments of the prostate gland, strictures of the urethra, and other causes,
the common catheter could not be passed into the bladder. Dr. Physick
communicated an account of this case to Dr. Miller, which is published in
the New York Medical Repository, vol. vii. p. 35, together with his me-
thod of preparing the instrument, subsequently described in Dorsey’s Ele-
ments of Surgery; some experiments on the treatment of gum elastic by
spirit of turpentine and ether, and, also a method of coating catheters with
gum elastic.

In the treatment of strictures in the urethra. Dr. Physick displayed the
most enviable degree of skill. It is true, he made the management of this
disorder a particular study, and the tact and dexterity which he exhibited
in dilating a stricture, was sufficient to excite the warmest admiration.—
What department of surgery indeed was there which was not in some
way or other enriched by his labours? Among his other contributions,
however, let us notice his invention of an instrument, in the year 1795, for
the purpose of cutting through a stricture which had refused to yield to
the ordinary methods of treatment. This instrument consists in a lancet
concealed in a canula, which is passed down the stricture, and then the
lancet is pushed forward so as to effect its division. Afterwards, a cathe-
ter or bougie should be introduced and worn for some time, in order to pro-
duce the necessary permanent dilatation. The success attending this me-
thod of treating strictures, which have resisted all other attempts at dila-
tation, has now become familiar, and may be considered one of the most
important and useful operations in surgery. It should be stated also, that
in some cases of complete retention of urine from stricture of the urethra,
this method of dividing the stricture by means of the lancet has obviated
the necessity of puncturing the bladder.

If I mistake not, Dr. Physick was the first who pointed out to our sur-
geons the method of constructing the waxed linen bougie. He informed
me that soon after his return from Europe he was engaged in attendance
upon a patient, in conjunction with his much esteemed friend Dr. Wistar.
It so happened that in the treatment of this case there was occasion for a

108

Biography,

bougie of a particular size and shape. Dr. Wistar regretted very much
not possessing such an instrument, and he expressed his doubts of being
able to procure one. Dr. Physick told him that he need not be uneasy,
for that he would furnish the instrument; and accordingly he constructed
one himself of the precise kind which they wanted, to the great surprise
and gratification of Dr. Wistar.

I may mention that in the treatment of strictures of the urethra. Dr. Phy-
sick invaiiably preferred using waxed linen bougies of his own make to
either the metallic or imported gum elastic bougies. I do not hesitate to
assert, however, that from long practice and dexterity, he acquired the art
of making a most beautiful and perfect instrument of this kind. It is pro-
per, however, to state, that the gum elastic bougies which were imported
into this country in that day, were of a very inferior quality to those which
we now have. A general account of the method of preparing the waxed
linen bougies is contained in “ Dorsey’s Elements of Surgery.”

During the years 1797, 1798, and 1799, the yellow fever reappeared in
our city, and Dr. Physick was again found in the foremost rank of those
who had to contend against its ravages. Whilst engaged in the perform-
ance of his duties, in the year 1797, he was attacked himself, for the second
time, with the fever, and his illness was so severe that for some time but
slight hopes were entertained of his recovery. His convalescence was
exceedingly slow, and he was left in such an enfeebled state 'hat he was
advised by his medical friends to make an excursion into the country, in
order to recruit his strength. He accordingly took this opportunity of
paying a visit to his brother, who was living upon a beautiful farm, situated
on the banks of the Susquehanna h, in Cecil county, Maryland. He was
somewhat amused, whilst performing this journey, at being informed by an
innkeeper on the road that Dr. Physick of Philadelphia was dead. His
health was greatly benefitted during the period of his sojourn with his bro-
ther, and it appears that he conceived a warm attachment to the place;
inasmuch as after the death of his brother, many years subsequently, he
became the purchaser of the estate, and during the latter years of his life
he was accustomed to spend a part of every summer upon it.

During the prevalence of the yellow fever in 1798, Dr. Physick was
again resident physician at the Bush Hill Hospital; and upon leaving the
institution, after the subsidence of the epidemic, he was presented in a flat-
tering manner by the board of managers, with some valuable silver plate,
as an acknowledgment of their “ respectful approbation of his voluntary
and inestimable services.”

In the winter of 1798, Dr.' Physick read before the “Academy of Me-
dicinocof Philadelphia,” an account of “ Some Experiments and Observa-
tions on the mode of operation of mercury on the body.” This paper was
subsequently published in the New York Medical Repository, vol. v. p. 288.
The result of these experiments and observations goes to disprove the
opinion that the different preparations of mercury produce their effects on
the system in consequence of their being absorbed and carried into the
blood. The experiments made by Dr. Physick in order to detect the pre-
sence of mercury in the blood and saliva of patients undergoing salivation
from that article, were repeated by Dr. Seybert, but both were unable to
discover the presence of the metal, owing to the imperfect state of chemis-
try at that period.

I have already stated, that in consequence of the untiring zeal of Dr.

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Memoir of Dr. Physick.

Physick in investigating the nature and phenomena of the yellow fever,
aided by the ample opportunities which he enjoyed of prosecuting his re-
searches, he was led to the adoption of some views which were not only
of an interesting and novel character, but such also as had a most important
bearing in elucidating the true pathology of the disease, and in establishing
in consequence more correct therapeutic indications. It was after the sub-
sidence of the epidemic of 1799 that he published in the New York Medi-
cal Repository, “Some Observations on the Black Vomit.” In this com-
munication he relates a series of careful and well conducted experiments,
which prove most conclusively that the matter of black vomit, so far from
being poured out by the vessels of the liver, as was the commonly received
opinion, is produced by a secretion from the inflamed vessels of the stomach
and intestines. Those observations, showing that the effusion of black
vomit must be regarded as one of the modes in which violent inflammation
of the stomach has a disposition to terminate, not only went far in destroy-
ing the preconceived notions entertained by many physicians, that the yel-
low fever was a disease of debility, and that the black vomit was to be
regarded as a putrid phenomenon, but also confirmed most satisfactorily the
propriety of the antiphlogistic method of treatment.

The year 1800 formed a most eventful one in the life of Dr. Physick.
During this year he formed a matrimonial alliance with Miss Elizabeth
Einlen, a highly gifted and talented lady, and daughter of one of the most
distinguished ministers of the Society of Friends. By this marriage he
had four children, two sons and two daughters, all of whom are now living.

In the year 1800, a request was made to Dr. Physick in writing, by a
number of gentlemen engaged in attending the medical lectures delivered
in the University of Pennsylvania, that he would lecture to them on sur-
gery. Among these gentlemen, who so fully appreciated his extraordinary
qualifications, was included our present pre-eminently distinguished Pro-
fessor of the Theory and Practice of Medicine, Dr Chapman.

No man could feel more deeply the solemn responsibilities attendant upon
such an enterprise than Dr. Physick. After mature deliberation, however,
he determined to accede to their request, and this may be considered as
the commencement of his I ’.hours as a lecturer.

The following anecdote, related to me by the doctor himself, will exem-
plify the ardour and zeal with which he entered upon the performance of
his duties, and it illustrates also most happily the great advantages which
may be derived from a w»rd of encouragement and approbation, coming
from a source in which entire confidence is reposed.

After preparing the lecture introductory to his course, he committed it
to memory. Among the persons invited to be present at its delivery was
his valued friend. Dr. Rush, The scene was a trying one to Dr. Physick.
It was the first time he had ever publicly addressed an audience. I have
been informed, however, that he acquitted himself extremely well. At
the close of the lecture. Dr. Rush stepped up to him, gave him his hand,
and congratulated him upon his success, saying to him very eaiphati-
cally, “ Doctor, that will do — that will do — you need not be apprehen-
sive as to the result of your lecturing — I am sure you will succeed.”
Dr. Physick never foro-ot Dr. Rush’s kind manner to him on this occasion.
He assured me that it exerted a considerable influence in strengthening and
confirming his resolutions to persevere. It is needless for me to say that
No. XL VII.— May, 1839. 10

110

Biography,

Dr. Rush’s predictions respecting Dr. Physick’s ultimate success in lectur-
ing were fulfilled to the utmost. Five years subsequently to that period,
the Professorship of Surgery was created in the University of Pennsylva-
nia, and Dr. Physick was elected to the chair.

In the year 1801, Dr. Physick was appointment Surgeon Extraordi-
nary^^'* and also one of the physicians, to the Philadelphia Almshouse In-
firmary. I am not aware that any appointment similar to the former has
been since made in that institution.

In 1802, he published in the New York Medical Repository, a case of
hydrophobia. In this communication he gives an account of the appear-
ances observed on dissection; and as a means of affording relief in sinular
cases, he suggests, in conjunction with other remedies, the propriety of
performing the operation of tracheotomy. The following quotation is suf-
ficiently explanatory of the views which he entertained.

“ Reflecting on the symptoms which took place in the case above related, it ap-
peared to me, that the dread of water arose chiefly from the convulsive or spasmodic
contraction of the muscles of the glottis, which rendered the patient unable to
breathe, and involved him in all the horrors of impending suffocation. When
asked why he could not drink, he answered, that whenever he attempted to
swallow any thing it took his breath away.”

“ Under the influence of these opinions, I am disposed to believe, that trache-
otomy would have saved my patient, at least for a time, if it had not altogether
prevented the fatal termination of the disease. I cannot suppose that the spasms
of the muscles in hydrophobia would be attended with much danger to life, were
it not for their influence in suspending respiration.” * * * ♦

I am not informed that he ever had an opportunity of testing the value
of the foregoing suggestion, by the performance of the operation.

About this period, it may be said that the talents and acquirements of
Dr. Physick began to be extensively known and appreciated, not only by
the members of his own profession, but also by others. I may mention,
that in this same year, (1802,) he was elected a member of the Arnericaa
Philosophical Society, a well merited tribute due to his rising greatness.

This year Dr. Physick devised and executed an operation which forms
one of the most brilliant achievments of modern surgery, and has been pro-
ductive of the most beneficial results to suffering humanity. On the 18th
of December, he performed, in the Pennsylvania Hospital, his celebrated
operation of passing a seten between the ends of an ununifed fractured hu-
merus, for the purpose of causing a deposition of callus, and thereby pro-
ducing the consolidation of the broken bone. The patient was a seaman,
who had had the misfortune to fracture his left arm, eighteen months pre-
viously whilst at sea; and in consequence of the bones not having united,
the limb was rendered nearly useless. At the expiration of five months
after the performance of the opei alien he was discharged from the Hospital
perfectly cured. Dr. Physick published an account of this case in the
Medical Repository of New York, vol. i. 1804; and it was republished entire
in the Medico Chirurgical Transactions of London, vol. v. 1819.

It so happened that, in the year 1830, I was requested to visit a patient
who w'as lying dangerously ill with remitting fever. A few days after my
first visit, in riding past his door in company with Dr. Phvsick, feeling
very uneasy about the condiiinn of my patient, I requested the Doctor to
step into the house and give me the benefit of his advice. He complied,

Ill

Memoir of Dr. Physick.

and upon entering the sick man’s chamber he immediately recognised him
as the individual upon whom he had performed the operation which 1 have
just described, twenty-eight years previously. Upon questioning the pa-
tient he informed us that the arm which had been broken was quite as
strong as his other arm, and that he had never sustained any inconve-
nience from the operation. The man died; and having obtained permis-
sion to make a post mortem examination, I procured his humerus, which
I still have in my possession, and regard it as one of the most interesting
and valuable pathological specimens extant. At the place of fracture, the
two ends of the bone are perfectly consolidated by a mass of osseous matter,
in the centre of which there is a hole, through which the seton had passed.

Since the performance of Dr. Physick’s first operation, this method has
been resorted to with entire success in numerous instances by himself and
other surgeons, for the cure of ununited fractures, not only of the hume-
rus, but also of some other bones. That this operation, like all others, oc-
casionally fails, must be admitted; it is, however, generally conceded that
it possesses many advantages over the method not unfrequently resorted
to, of cutting down to tho ends of the bone and sawing them off, as re-
commended by Mr. Charles White, of Manchester.

In describing that process M. Boyer declares it to be “painful, terrify-
ing, and of dubious event.” He once performed it on account of a pre-
ternatural Joint, situated in the middle of the humerus; the limb mortified,
and the patient died on the sixth day. Independently of the greater ha-
zard attending this method of operating, it is unquestionably much more
painful than Dr. Physick’s; and although occasionally it succeeds perfectly,
in many instances it has entirely failed.

It is a matter of much surprise and regret, that Mr. William Lawrence,
of London, a gentleman distinguished for brilliant talents and extensive
learning, in speaking, in his surgical lectures, of the different methods of
operating for the cure of ununited fractures, should greatly undervalue the
importance of Dr. Physick’s operation, and limit exceedingly its success-
ful results. To correct the false impressions which this statement might
create, and as an act of justice due to the distinguished inventor of the
operation, my friend Dr. Hays gave in his valuable periodical, the Ameri-
can Journal of the Medical Sciences, vol. vii, p. 267, a brief summary of
numerous cases of ununited fracture successfully treated by means of the
seton, collected from various sources. Dr. Physick was extremely grati-
fied at the able manner in which Dr. Hays vindicated the merits of his
operation, for the cure of artificial joint by means of the seton.

Dr. Physick’s private journal^ and also a book of cases, kept by his
nephew. Dr. Dorsey, clearly evince that at this period Dr. Physick was
occupied in attending to a most extensive and laborious practice. In Dr.
Dorsey’s note book are recorded the most interesting cases and operations
occurring in the practice of Dr. Physick, to which he was a witness. It
is exceedingly probable, that during that period there were but few opera-
tions performed by Dr. Physick, at which Dr. Dorsey was not present; for
in some places he gives an account of important and capital operations
performed almost daily by his uncle.

It has always been a subject of deep regret with tho profession, that Dr.
Physick should have evinced throughout his whole life such an extreme
reluctance to the publication of the results of his valuable observations and

112

Biography,

experience. What a fund of knowledge has in this manner been permitted
to pass away, which might have been happily applied to ameliorating the
miseries of humanity? Strange as it may appear, I unhesitatingly assert,
that posthumous fame was not sought after by Dr. Physick. I am well
convinced, however, that in the latter years of his life, he regretted very
much himself that he had not published more for the benefit of his fellow
beings; but at this period his disinclination and habits had become so con-
firmed that it was impossible for him to change them.

From the paucity of Dr. Physick’s printed communications, and their
considerable value, I make no apology for briefly noticing them. It has
been necessary to collect them from various Journals. I consider it un-
necessary to enlarge upon them, however, inasmuch as my friend, Dr. Ben-
jamin Hornor Coates, is engaged in preparing an edition of Dr. Physick’s
works, with commentaries on his doctrines and practices.

In Coxe’s Medical Museum, vol. i. for the years 1804-5, there are pub-
lished by Dr. Physick three papers, communicating cases occurring in his
practice, together with practical suggestions, and by Mr. Bishop two, giving
an account of improvements and modifications upon instruments made after
the directions of Dr. Physick.

In the first paper. Dr. Physick communicates the particulars of a case
of varicose aneurism, occuriing at the bend of the elbow, in consequence
of the artery being wounded in the operation of venesection; the lancet
being pushed into this vessel through the vein. The blood escaped from
the artery into the cellular membrane between it and 'into the yein, and
formed a large pulsating tumour, in which the particular thrill accompany-
ing varicose aneurisms was distinctly felt. The sac formed out of the cel-
lular tissue went on increasing in size, until it became so firm that the blood
was forced from it into the vein through the puncture in its lower side,
with sufficient force to distend it very considerably for two or three inches
above and below the sac. The size of the forearm had much diminished,
and the hand was constantly cold. At length the skin covering the swell-
ing became so thinned that the patient was very apprehensive that it might
suddenly rupture. In this state Dr. Wistar and Dr. Physick advised an
operation.

Dr. Physick performed this in the following manner. He divided the
skin and cellular membrane covering the swelling, and then dissected com-
pletely round the tumours. After this he tied the trunk of the vein above
and below its enlargement; and next he tied the artery above and below
the sac. He finally dissected out the whole of the parts between the lig-
atures, including the aneurismal sac. Upon opening the sac its inside
was found every where incrusted with bony matter; but the artery was
perfectly sound and natural. In three weeks the wound healed, and the
patie ,t very soon recovered the entire use of the limb.

The second publication was a description by R. B. Bishop^ surgeons’
instrument maker, of the gorget, as constructed according to Dr. Phy-
sick’s plan. I have already noticed this modification of the gorget in a
former part of this memoir.

The third publication in the Medical Museum was exceedingly valuable
and interesting, being the first annunciation of a new method of treat-
ment, suggested by Dr. Physick, for the relief of a formidable disease,
and one which had previously baffled the skill of the most experienced

Memoir of Dr, Physich. H3

physicians. In this communication Dr. Physick recommends the use of
blisters for the purpose of arresting the pmgress of mortification. He
states that he was induced to resort to this practice from a knowledge
of blisters having been employed advantageously in curing erysipela-
tous inflammation; a practice which he learned from the late Dr. J. Pfeifler.
In this paper Dr. Physick gives an account of two cases of mortifica-
tion which came under his own notice, in which he applied blisters to the
mortified parts with the most beneficial efiects. He also publishes two
letters, one addressed to him by his friend. Dr. Benjamin Rush, and the
other by Dr. Church; each of whom describes a case of mortification in
which he employed blisters, upon Dr. Physick’s recommendation, with
perfect success.

It is scarcely necessary for me to add, that since that period, blisters
have been frequently employed for the purpose of arresting the pro-
gress of gangrene and mortification, with the most successful results.
As a local remedy, I believe it is entitled to a decided preference over all
others. To be effectual, it should be large enough to cover the sound
parts adjacent to the disease.

The fourth publication consists of a description, by R. B. Bishop, of the
curved bistoury, as improved by Dr. Physick, for the operation of fistula
in ano, with a plate. This well known instrument, thus modified by Dr.
Physick, combines the advantages of both the blunt and sharp-pointed
bistoury. Since the period of its invention it has been in general use.

In the fifth communication Dr. Physick describes the history of a case
of luxation of the thigh bone forward, and the method which he em-
ployed for its reduction; and the paper is accompanied by a plate. A.1-
though this case is an exceedingly interesting one, it is unnecessary to
notice it more particularly.

I have already stated, that at the period when Dr. Physick commenced
his professional career, the organisation of the medical department in the
University of Pennsylvania was so imperfect, that the chairs of Anatomy
and Surgery were combined. To remedy this acknowledged deficiency,
in the year 1805, the chair of Surgery was made distinct from that of
Anatomy, and Dr. Physick was elected, I believe unanimously, Professor
of Surgery.

It should be borne in mind, that he had previously, in the year 1800,
complied with a request, made to him by a number of gentlemen engaged
in the study of medicine, to deliver lectures on surgery. These lectures
were delivered in the Pennsylvania Hospital; and he exhibited such posi-
tive and satisfactory evidence of his entire competency to the task which
he had assumed, that he very soon became exceedingly popular as a teacher,
and added greatly to his fame.

It is more than probable that the position which he now held as a lec-
turer on surgery, exerted no little influence in producing the change
which was made in the medical faculty.

I presume it will not be denied that, however great the advantages
may have been which accrued to Dr. Physick in consequence of his being
appointed Professor of Surgery in the University of Pennsylvania, the
institution itself derived equal advantages from his connection with its
medical faculty. It is certain that, soon after his appointment, the
number of students who resorted to this citv to attend the medical lec-

10*

114

Biography,

tures, greatly increased; and although I freely admit that there were
many co-operating circumstances, his efforts in behalf of the school being
seconded by colleagues who possessed talents of so retulgent a character
that the light shed from them has not yet passed away, still it is worthy
of record, that the zenith of Dr. Physick’s fame and usefulness was the
period at which the University of Pennsylvania attained the acme of its
reputation.

Having shown that Dr. Physick’s efforts as a private lecturer were at-
tended with the most entire success, we can readily believe that he was
quite prepared to enter upon the duties of his new appointment. Inas-
much however, as this situation opened to him a more extensive field of
action than he had previously cultivated, he felt himself called upon to
make renewed exertions.

It is almost impossible to conceive of the great amount of labour which
he was in the habit of performing daily, during this period of his life.
He has frequently told me that it was his custom, throughout the winter
months, to rise at four o’clock in the morning. Tfiis hour being too early
to disturb a servant, he was obliged to arrange his own fire. He woidd
then sit down to his desk and prepare his lecture for the day; after which
he would dress himself, and then take his breakfast, and leave his house
between eight and nine o’clock, to attend to an extensive and laborious
practice. In addition to all this, he discharged his duti^’s as Surgeon to
the Pennsylvania Hospital, and to the Alms House Infirmary. He used
often to remark, that in order to obtain entire success as a practitioner
of medicine, it was necessary to work hard. He told me that in Lon-
don this idea was conveyed by the emphatic expression “ Doctor or Mr.
is working his way into business.” It will be conceded that no por-
tion of his success ever came to him gratuitously; on the contrary, he
made laborious exertions to obtain it.

Dr. Physick’s manner as a public lecturer was extremely grave, dig-
nified and impressive. His style was clear, simple and chaste. He
was uniformly careful never to say too much. His choice of lan-
guage was remarkably good, and he possessed the happ) faculty of com-
municating knowledge agreeably and clearly to a degree which I have
never known surpassed. Perhaps one great reason for this was, that he
never undertook to instruct others upon subjects which he did not clearly
conjprehend himself. He a,ttemptedno display of oratory; neither did ho
permit his reason and imagination to run wild in the regions of theory
and fancy. He found much better employment for his mind in constantly
studying the realities of life, and in reflecting upon the best methods of
promoting the welfare of his fellow creatures. His lectures were care-
fully prepared and written out. He did not at all approve of extempo-
raneous lecturing; as he thought that in lecturing upon scientific subjects,
and more especially such as involved the lives and happiness of our fel-
low beings, no man had a right to place so much confidence in the strength
of his memory as is implied in that practice.

Dr. Physick’s course of lectures on surgery was eminently valuable,
from being founded principally upon his own practical knowledge and ex-
perience, and also from his discarding all mere hypotheses; besides which
his lectures derived an additional attraction and importance from the cir-
cumstance that his reputation for stern integrity and strict veracity was

115

Memoir of Dr* Physick,

so well known and established, that whenever he asserted facts to be true,
they were innplicitly believed.

As a letter-writer he was exceedingly exemplary and peculiar. I regret
very much not having the privilege of inserting a few of his letters in this
memoir. In general they were remarkably brief and pithy. He was ex-
cessively annoyed at receiving, and being obliged to read letters of an un-
meaning and unnecessary length. It was the same with respect to books.

I have often heard him complain of the hardship of being obliged to read
through a volume of two or three hundred pages, to get at ideas which
might have been embodied in ten or twenty.

'j'he year 1809 has been rendered memorable in the annals of surgery,
by the invention and execution of an operation by Dr. Physick, which,
for the brilliancy of its conception and the important practical results
which have ensued from it, has excited admiration and attention through-
out the medical world.

In the month of January of that year, Dr. Physick performed his ope-
ration for the cure of artificial anus, which, as is well known, was com-
pletely successful. To those who are unacquainted with the nature of the
loathsome malady just named, it is impossible to convey any adequate idea
of the many afflicting circumstances connected with it; suffice it to say,
that the unhappy sufferer is rendered disgusting, not only to himself, but to
those around him. There are probably few persons who would not prefer
death to existence complicated with a train of such insupportable evils.
What an immense amount of obligation are we not under to him who, by
the force of liis genius and profound acquirements, was enabled to triumph
over obstacles of such fearful magnitude, and provide a remedy for so hope-
less a calamity! We are happy to say, that the debt of gratitude has not
been lefi unpaid, and that Dr. Physick has received the homage of the
profession for having achieved this invaluable discovery.

His method of performing this operation is now so well known that it
is not necessary for me to communicate the details of it here. He was
negligent in not making a printed publication of the method at the moment
of its discovery; he, however, publicly taught it, in his surgical lectures
annually, from 1809 to 1821, to classes of several hundred students.

You are aware that some years subsequently, one of the most distin-
guished surgeons of Europe, the late Baron Dupuytren, performed an ope-
ration upon a somewhat modified plan, but with similar views, and founded
upon precisely the same principles; and that he claimed tlie merit of having
invented the method, and appropriated to himself the consequent honours.
It did not, however, by any means comport with the views entertained by
the surgeons of our country, that the distinguished head of the profession
should be dispossessed in so unceremonious a manner, of honours exclu-
sively his own. Accordingly, in order to place the matter in its proper
light, my friend Dr. Benjamin Hornor Coates, obtained from Dr. Physick
the date of the operation, together with ample notes of the case, taken from
his private journal, now in my possession, and also procured an account of
the case as recorded in the manuscript case book of the Pennsylvania Hos-
pital; and then published a full account of Dr. Physick’s operation in the
North American Medical and Surgical Journal for October, 1826, together
with some valuable remarks upon Baron Dupuytren’s method of operating,
proving in the most satisfactory manner that the justly celebrated French
surgeon promulgated the idea of the operation long after Dr. Physick.

116

Biography*

Baron Dupiiytren exhibited reluctance to yield his claims to this disco-
very; but before his death, he was, I believe, fully satisfied of the justice
of br. Physick’s claims to priority.

In the year 1835, Dr. Physick was exceedingly gratified at receiving a
letter from his relative. Dr. Robert R. Dorsey, then residing in Paris, in
which he informed him that M. Roux, the present distinguished successor
to Baron Dupuytren as surgeon in chief to the Hotel Dieu, stated in a lec-
ture introductory to his clinical course on surgery, in lire presence of Pro-
fessor Mott of New York, Dr. A. B. Tucker of this city, and a large class
of medical gentlemen, tliat to Dr. Physick was unquestionable due the
honour of having invented tlie operation for artificial anus, which had been
clain»ed by his predecessor, Baron Dupuytren.

In the third volume of the “Eclectic Repertory,” for October, 1812,
Dr. Physick published an account of a new method which he had employ-
ed for the purpose of extracting poisonous substances from the stomach.
In this communication he furnished the particulars of two very interesting
cases, in which twin brothers, of the age of three months, had been thrown
into a state of complete stupor, from which they could not be roused, from
having had administered to each of them by their mother, one drop of lau-
danum, in order to allay the restlessness attendant upon whooping cough,
under which they were both labouring. It appears that the vial from
which the laudanum had been given had contained, several weeks previ-
ously, nearly one ounce of that medicine; but in consequence of having
been left without a cork, it had evaporated so that the mother was able to
obtain one drop only for one of the children, and in order to procure another
drop, she pul two drops of water into the vial, stirred it about, and then
gave a drop of it to the other child. The poor mother was entirely igno-
rant of the immense additional strength which the dose had gained, in con-
sequence of the evaporation which had taken place.

Each of these children had been thrown into convulsions. When Dr.
Physick arrived at the house, he immediately directed an emetic of ipeca-
cuanha to be given. This, however, could not be accomplished, as the
children were incapable of swallowing. “ The countenances of the chil-
dren became livid, their breathing very laborious, with long intervals be-
tween the limes of each inspiration, and the pulse in each very feeble.
The pulse and respiration had almost ceased; and, indeed, the pulse could
not be perceived, except a faint stroke or iw'o, after that kind of imperfect
and convulsive inspiration which is commonly observed in children just
before actual death, accompanied w'ilh a convidsive action of the muscles
of the mouth and neck.” Under these circumstances. Dr. Physick saw
that no lime was to be lost, and as the children could not swallow, he de-
termined to inject an emetic into their stomachs. For this purpose he in-
troduced a large flexible catheter down the (esophagus, and through it he
injected one drachm of ipecacuanha mixed with water, by means of a com-
mon pewter syringe. After waiiing some little time for the operation of
the emetic in vain, the stomach having in both instances completely lost
its power of action, he injected a quantity of warm water, and then with-
drew it by means of the syringe. He now repealed these operations again
and again, until he had washed out the stomach thoroughly and removed
all their contents.

By the lime these operations were completed, however, all signs of ani-
mation in both children were entirely lost. Discouraging as these circum-

117

Memoir of Dr, Physick,

stances were, the doctor determined to persevere in his efforts to restore
life; and accordingly he injected into their stomachs some spirits, mixed
with water, and a little vinegar; and he also made use of external stimuli.
In a few minutes the pulse and respiration returned in each child, and in
the course of a short time both were regularly performed. One of these
children, however, expired the next morning; the other completely reco-
vered.

In a note to this communication Dr. Physick states, that the idea of washing
out the stomach in cases where large quantities of laudanum or other poisons
had been swallowed, occurred to him at least twelve years previously, and
that he had constantly recommended it in his lectures. He states also that
his nephew. Dr. Dorsey, had performed the operation of washing out the
stomach in such a case in the year 1809. At the time Dr. Physick made
this communication, he was under the full impression that he was the
earliest inventor of this operation. In the same volume, however, of the
Eclectic Repertory, p. .380, there is published a letter from him, addressed
to the editors, in which he says that he considers it an act of justice to in-
form his medical brethren that the merit of prior invention belongs to Dr.
Alexander Munro, Jr. of Edinburgh, who published it in his inaugural
thesis in A. D. 1797. Dr» Physick was entirely ignorant of this fact until
he saw it mentioned in Dr. Munro’s work on morbid anatomy, which he
had but very lately received.

Conceding to Dr. Munro all the honour arising from the discovery of
this valuable method of treatment, it must be admitted that Dr. Physick is
entitled to the grateful thanks of the community for having introduced it
into practice. It is scarcely necessary for me to say that this operation is
now one almost daily performed and that by it very many persons have
been rescued from an untimely grave.

In the winter of 1813-14, Dr. Physick suffered from a severe attack of
typhus fever. On this occasion his illness was so extreme, that his medi-
cal friends despaired of his life for some time. He gradually convalesced,
but his constitution did not entirely recover from the shock which it then
received. From this period he never enjoyed what might be called unin-
terrupted health. His powers of digestion became exceedingly impaired,
whence ensued a train of most unpleasant dyspeptic symptoms. He be-
came subject also to frequent attacks of catarrh, and his susceptibility to
this condition increased to such an extent that he was obliged to observe
the most rigid precautions in order to guard against it. His method of
treatment when labouring under a severe cold, required confinement to a
warm room; and in fact he accustomed himself to a degree of heat in his
apartments which to many others was almost insupportable. In addition
to this he always employed the strictest antiphlogistic treatment, as re-
garded his diet and remedial agents. I think that he injured himself, and
in a measure produced the very enfeebled and prostrated condition of his
system which attended him during the latter years of his life, by the ex-
cessively reducing system of treatment to which he had recourse.

The small amount of food of which he would sometimes permit himself
to partake, is almost inconceivable; and this for many days together. I
frequently expressed to him my regrets respecting the meagre diet he was
using; and upon one occasion I dissented roundly from the propriety of
such a course of dieting. He replied that he regretted it very much liim-
self, and that he wished he could indulge in more generous living, but that

118

Biography.

he had accustomed his stomach for so long a time to abstinence from rich
food, that it was impossible now to make any change.

About the period to which we are alluding he began to experience cer-
tain unpleasant symptoms, indicative of a diseased condition of the heart,
and which eventually terminated in organic affection of that organ, and
doubtless laid the foundation for the hydropic complaint of which he died.

Among the complicated forms of disease to wliich he was subjected,
must also be enumerated nephritic disorder, with calculous concretions in
the kidneys. It is impossible for language to describe the pain and agony
which he frequently endured from the passing of the small calculi through
the ureters into his bladder. Upon one occasion, about ten years previous
to his death, I knew him to be for near two hours without any pulse per-
ceptible at the wrist, in consequence of intense suffering, caused by the
lodgment of a small calculus in the ureter. It remained fixed in this situa-
tion for some days, and grew to the size of a small pea; it finally passed
into the bladder, and was discharged a few minutes subsequently through
the urethra.

The practical knowledge and experience which Dr. Physick derived
from the careful and minute attention which he bestowed not only upon
every department of his profession, but also, I may say, upon each sepa-
rate anil individual case of disease which came under his notice, enabled
him to suggest numerous modifications and improvements which have ex-
erted the happiest influence in elevating the condition of our science. It
would be impossible, in a communication of this nature, which has already
exceeded the limits originally proposed, to give even a brief outline of the
many valuable inventions for which we are indebted to him. In order to
do this, it appears to me, that it would be necessary to review almost every
professional act of his life; because there was no form of disease of which
he undertook the management, in which he did not exercise a tact and
method of treatment peculiarly his own. I do not mean to say that in
every case he prescribed a new remedy, and one original with himself. —
My meaning is that he invariably modified either the dose, or the prepara-
tion, or the time of its administration, or the method of its application,
according to his own proper and peculiar views.

It may not be deemed uninteresting to mention the particulars of a case
in which he was instrumental in preserving the life of a valuable and dis-
tinguished lady, by the following simfde treatment. This lady was brought
on to Philadelphia labouring under an attack of dyspepsia of the most ag-
gravated character. The irritability of her stomach was so great, that it
bad rejected every variety and form of nourishment which could bethought
of, and her system consequently was so much weakened and prostrated,
that she appeared to be absolutely dying of inanition. When Dr. Physick
saw her, after proposing a variety of articles, he asked her whether she
had ever, since her attack, tried to take milk. She replied that she had
often taken it, but her stomach very soon rejected it. He then asked her
whether she did not think that her stomach would retain the half of one
tumblerful of milk. She said, no. He repeated his questions. Would it
retain one wineglassful? No! Would it retain a tablespoonful? No! He
then told her that he was under the impression that she could retain in her
stomach one teaspoonful of milk; and accordingly he prescribed the arti-
cle for her, to be taken in that quantity, at repeated intervals. The lady
attended to his prescription, and was ultimately restored to perfect health.

119

Memoir of Dr. Physick.

Among other improvements suggested by Dr. Physick, I should men-
tion, that in the Eclectic Repertory, vol. vi, for the year 1816, he publish-
ed an account of a method which he had proposed for forming ligatures
out of animal fibre. He had repeatedly noticed, that after the performance
of operations, the wound was prevented from healing, and the patient was
subjected to the greatest inconvenience and distress, in consequence of the
ordinary ligatures, formed out of silk or flax, remaining fixed in the wound
sometimes for many weeks or even months. Dr. Physick considered it an
object of extreme importance to obviate these inconveniences; and ac-
cordingly he proposed the use of animal ligatures, by means of which an
artery could be secured for a sufficient length of time to cause the oblitera-
tion of the vessel, and the ligature, being decomposed and dissolved,
would escape in the course of a few days.

His views upon this subject will be fully explained by the following
quotat'on. “ Several years ago, recollecting how completely leather straps
spread with adhesive plaster, and applied over wounds for the purpose of
keeping their sides in contact, were dissolved by the fluids discharged
from the wound, it appeared to me that ligatures might be made of leather,
or of some other animal substance, with which the sides of a bloodvessel
could be compressed for a sufficient time to prevent hemorrhage; that such
ligatures would be dissolved after a few days, and would be evacuated with
the discharge from the cavity of the wound.”

From this period he continued to employ animal ligatures almost exclu-
sively up to the time when he left off operating. I regret that notwith-
standing the advantages which these ligatures possess, they are hut seldom
used by the surgeons of the present day. 1 can attribute this neglect of
them to noihinj^ but the slight trouble attendant upon their preparation.

Some lime subsequently to Dr. Physick’s publication upon tliis sul^ject,
it was shown that the idea of preparing ligatures from animal fibre had
been suggested a long time previously by one of the older surgeons. It is
scarcely necessary f<»r me to say, that he was entirely ignorant of this fact,
and that at the time he was under the full impression that the suggestion
had originated with himself.

Whilst upon this subject, it may not be amiss to give an account of
a very ingenious contrivance, which Dr. Physick employed for the pur-
pose t)f facilitating the discharge of ligatures which remained fixed in the
cavity of wounds, either in consequence of being penetrated by new granu-
lations, or from other causes. In such cases he twisted the ligature very
firmly, and then secured it to the adjacent skin, by means of a small strip
of adhesive plaster. The eflect of this twisting is to tighten the noose at
the extremity of the ligature, so as to compress completely the parts con-
tained within it; and in addition to this, the natural tendency of the liga-
ture to untwist itself keeps up a constant action and pressure upon the
parts, and thereby causes ulceration. We have known several ins ances in
whitdi ligatuies which had been retained for a long period in wotmds, have
been extricated by resorting to this simple process. I may stale that Dr.
Physick had strong objections to the use of silk ligatures, and in cases
where he did not employ animal ones, he invariably preferred iliose made
of flaxen thread or bobbin. He was of the opinion that silk ligatures were
more apt to slip.

It is my impression that the period which we are now commemorating
may be considered as that at which his professional engagements had ac-

120

Biography.

quired their greatest extent. His preeminence, both as a physician and a
surjjeon, was at that time so generally conceded in this city, as to lead to
the greatest demand for his professional services. In addition to this his
surpassing fame and reputation were so completely established and so
widely disseminated, as to induce strangers from all parts of our country to
resort to Philadelphia, in order to be benefiued by his skill and experience.

It follows also as a natural consequence of his exalted position, that
many persons who could not make it convenient to leave their homes,
would apply to him for his advice and opinions in writing; so that in ad-
dition to his other labours, much of his time was occupied in keeping up
an extensive correspondence.

I have already shown that his health was considerably impaired; and it
is probable that about this period he must have been deeply sensible of his
increasing infirmities, inasmuch as he thought proper, in 1816, to resign
his situation as Surgeon to the Pennsylvania Hospital. He had received
his appointment in 1794; consequently he served the institution twenty-
two years. Some time previous to this he had resigned his situations in
the Philadelphia Dispensary, and in the Alms House Infirmary.

In the year 1819, Dr. Physick resigned his chair of Surgery in the
University of Pennsylvania, and was transferred to that of Anatomy,
W'hich had become vacant the preceding session by the death of his ne-
phew, Dr. John Syng Dorsey.

The premature death of the lamented Dorsey plunged Dr. Physick into
the deepest affliction, and had the effect of creating a melancholy gloom,
which overshadowed the remainder of his existence. Dorsey, of all others,
was fitted to cheer and solace the declining years of his uncle. He had
been regularly educated under the immediate inspection and superinten-
dence of Dr. Physick, had imbibed from him his early lessons of wisdom
and knowledge, and at a more matured period of his life, fully adopted the
principles and doctrines of his preceptor. Advantages like these, aided by
talents of a brilliant and comprehensive order, enabled Dorsey at an unusu-
ally early period of his life, to assume the most elevated and distinguished
rank in his profession. Relentless death, however, seized upon his prey,
whilst in the midst of his honours and his usefulness.

It was always a source of deep regret with Dr. Physick’s immediate
family and friends, that his comforts in the evening of his days, and whilst
labouring under physical infirmities, should be so greatly interrupted by
translating him frotn the chair of Surgery to that of Anatomy. We had
positive assurances from himself that the change was contrary to his own
wishes and inclination: how far the interests of the institution to w'hich
he belonged may have been promoted by it, I do not mean to inquire.
My own impression is, however, and I believe I am not singular in the
opinion, that if he had continued in the chair of Surgery up to the period
when he retired from the University, it would have numbered in its cata-
logue of students many more than it has ever showm.

In the Philadelphia Journal of the Medical and Physical Sciences, edi-
ted by Professor Chapman, vol. i, for the year 1820, Dr. Physick gave
an account of the method which he employed for the removal of scir-
rhous tonsils, and hemorrhoidal tumours. 'I'his consisted in strangulat-
ing ilie tumours c(unpletely by means of a soft wire ligature passed
through a double cannula, and removing the wire at the expiration of
twenty-four hours; instead of allowing the instrument to remain applied,

121

Memoir of Dr. Physick.

as was formerly the custom, until the parts separated and were thrown
off, a process requiring a week or ten days. Experience has shown
this to be a valuable improvement on the old method. We can readily
imagine that the long-continued irritation kept up by the instrument would
be productive of a degree of pain and suffering from which it is desirable
to free the patient as soon as possible.

A few years subsequently, Dr.Physick became convinced that the best me-
thod of removing scirrhous tonsils was by excision. He contrived a very
ingenious instrument for this purpose, and also for excising the uvula; a
full description of which, accompanied with a plate, was published by
Dr. Hays, in the American Journal of the Medical Sciences, vol. i;
together with the very interesting case of a young lady, afflicted with,
a most obstinate cough, occasioned by an elongation of the uvula, who
was entirely cured by Dr. Physick, by means of the excision of a por-
tion of that organ. In vol. ii, of the same Journal, Dr. Hays, its edi-
tor, published the description and plate of a forceps, invented by Dr.
Physick, and employed in certain cases to facilitate the extirpation of
the tonsils, by means of his instrument. The forceps is so constructed,
that “ the tonsil may be seized, and drawn through the aperture to any
distance that may be deemed proper; when its extirpation can be im-
mediately effected.”

It is proper that I should state, that in cases of hemorrhoidal tumour,
where the complaint was of long standing, when the lining membrane of
the rectum was much diseased, and where the tumours were seated inter-
nally, Dr. Physick employed the ligature for their removal, as long as he
continued to operate. Under the circumstances just mentioned, he con-
sidered this method of operating far safer than using the knife, and
greatly to be preferred.

The following extract, taken from his communication on the use of
the double cannula and a wire, conveys a correct idea of his views upon
this subject. “ I have for many years been in the habit of performing
the same kind of operation for the extirpation of hemorrhoidal tumours.
The cannula used in this case should not be longer than about two
inches. When hemorrhoidal tumours are external and troublesome to the
patient, almost all surgeons, I believe, cut them off; but when their at-
tachments are within the anus, and the tumour only protrudes in the act
of evacuating the faeces, then their excision would be attended with great
risk of hemorrhage. This some have denied, but having twice witnessed
the fact to a very alarming extent, I wish on all such occasions to guard
against it. The extirpation of such tumours can be performed safely
by means of a ligature of either vegetable or animal substance; but the
most convenient and effectual I have ever tried, is a wire drawn at once
tight round its base, by means of the double cannula. This gives mo-
mentary pain, but it is not in all cases so severe as might be supposed. I
am not able to account for this circumstance; but some patients make no
complaint whatever, even though two or three tumours are operated on
at the same time, while others exclaim violently from its intensity. At
the end of twenty-four hours, and probably sooner, the wire may be re-
moved in the manner above explained. The tumour will be found shri-
velled and black, and in a few days will be separated and thrown off,
under the application of a soft poultice of bread and milk.”

Much has. been said respecting the intensity of the pain accompanying
No. XLVII.— May, 1839. 11

122

Biography.

the application of a ligature to hemorrhoidal tumours. I have, however,
repeatedly performed this operation, and not unfrequently the patients
have expressed surprise at the little suffering which they experienced.
Dr. Physick often related to me the case of a gentleman on whom he per-
formed two operations for the removal of hemorrhoidal tumours. In the
one he used the knife, and in the other the ligature; and the patient de-
clared that the knife caused him much greater pain than the applica-
tion of the ligature. It is proper to mention, however, that in order to
lessen the amount of pain. Dr. Physick considered it extremely impor-
tant to include within the ligature nothing but the hemorrhoidal tumour
itself.

It is undeniable that, in certain cases, the excision of hemorrhoidal tu-
mours is attended with the risk of fatal hemorrhage; and it is well known
that cases have been reported by the highest authority in surgery, in
which this operation has been followed by loss of life. I should suppose
that Baron Dupuytren’s cautions respecting this operation, in conjunction
with his directions for the suppression of the hemorrhage attendant upon
it, would be quite sufficient to deter a majority of surgeons from excising
internal hemorrhoids.

The last paper written by Dr. Physick, which I shall briefly notice, is
one which he published in vol. iii, of the Philadelphia Journal of the
Medical and Physical Sciences, in which he communicated the particu-
lars of a case of carbuncle, with some remarks on the use of the com-
mon caustic vegetable alkali in the treatment of this disease. For the
better comprphension of his views respecting the use of the caustic, he
divides the progress of carbuncle into three stages. The first or forming
stage is that in which the peculiar inflammation exists in the cellular tex-
ture under the skin. The second stage is that in which the inflammation
has terminated in the mortification of the parts. In the third stage an
ulcer remains, attended, however, with no peculiarities.

He says, “ In the first stage, all irritating treatment appears to be in-
jurious, by increasing the peculiar inflammation then existing, and thereby
extending it.”

“ In the second stage, the inflammation having ended in the death of
the cellular texture in which it was situated, a process begins for making
an opening through the skin, to allow the dead parts and acrid fluids to
pass out. The commencement of this process is pointed out by the ap-
pearance of pimples and small orifices, as above described; and it is at
this period that the application of caustic vegetable alkali upon the skin
so perforated, and on that covering the middle of the tumour, in quan-
tity sufficient to destroy it completely, proves highly beneficial. In all
the cases in which I have used the caustic in this manner, the suffering
of the patient ceased, as in Mr. Wharton’s case, as soon as the pain from
the caustic subsided. It operates by destroying in a few minutes that
portion of the skin covering the mortified parts, which, if left to be re-
moved by ulceration, would require several days for its completion, occa-
sioning the chief part of the pain and danger attendant on and consequent
to the disease.”

In the year 1821, Dr. Physick was appointed Consulting Surgeon to
the Institution for the Blind.

In 1822, the Phrenological Society of Philadelphia elected him its Pre-
sident.

Memoir of Dr, Physich

123

In 1824, he was chosen President of the Philadelphia Medical So-
ciety. He held tliis situation until the time of his death.

In 1825, January 6, he was appointed a Member of the Royal Acade-
my of Medicine of France; so far as I know, the first American who ever
received that honour.

In 1831, in consequence of his declining health, he felt it incumbent on
him to retire from the active duties of the University; and accordingly he
resigned his situation as Professor of Anatomy. In acknowledgment of
the extraordinary services which he had rendered, in elevating the charac-
ter of the school, and in promoting the advancement of medical science,
the institution, upon accepting his resignation, conferred upon him the
highest honour in its power, by electing him unanimously “ Emeritus
Professor of Surgery and Anatomy.”

Not the least among the improvements effected by Dr. Physick in the
methods of treating diseases, may be considered his management of af-
fections of the joints; and more especially that condition of the hip
joint, known by the name of “ morbus coxarius, or hip disease.”

I may mention generally, that his practice consisted in the application
of a carved splint, to keep the limb strictly at rest, and prevent the least
possible motion of the joint; and a course of active and long-continued
purging.

In the American Journal of the Medical Sciences, No. xiv, February,
1831, I published a detailed account of Dr. Physick’s method of treat-
ing morbus coxarius, accompanied with a plate, exhibiting the application
of the carved splint. The superiority of this method of treatment is
now so completely established in this conntry as to lead to its adoption by
the profession generally.

In October, 1831, Dr. Physick performed the operation of lithotomy
on Chief Justice Marshall. This case was attended with singular inte-
rest, in consequence of the exalted position of the patient, his advanced
age, and the circumstance of there being upward of one thousand calculi
taken from his bladder. It is well known that for several years^ previous
to this period. Dr. Physick had declined performing extensive surgical
operations. He felt somewhat reluctant to operate upon Chief Justice
Marshall, and ofiered to place the case in my hands. Taking all the cir-
cumstances into consideration, and knowing well that this would be the
last time that he would ever perform a similar operation, I felt desirous
that he should finish with so distinguished an individual; and accordingly
urged him to do it himself. Upon the day appointed, the Doctor per-
formed the operation with his usual skill and dexterity. I do not think I
ever saw him display greater neatness than on that occasion. The result
of the operation was complete success.

It will be readily admitted that, in consequence of Judge Marshall’s very
advanced age, the hazard attending the operation, however skilfully per-
formed, was considerably increased. I consider it but an act of justice,
due to the memory of that great and good man, to state, that in my opinion,
his recovery was in a great degree owing to his extraordinary self-posses-
sion, and to the calm and philosophical views which he took of his case,
and the various circumstances attending it.

It fell to my lot to make the necessary preparations. In the discharge
of this duty, I visited him on the morning of the day fixed on for the ope-
ration, two hours previously to that at which it was to be performed.

124

Biography.

Upon entering his room I found him eating his breakfast. He received
me with a pleasant smile upon his countenance, and said, “ Well, doc-
tor, you find me taking breakfast, and I assure you I have had a good
one. I thought it very probable that this might be my last chance, and
therefore I was determined to enjoy it and eat heartily.” I expressed the
great pleasure which I felt at seeing him so cheerful, and said that I hoped
all would soon be happily over. He replied to this, that he did not feel
the least anxiety or uneasiness respecting the operation or its result. He
said that he had not the slightest desire to live, labouring under the suffer-
ings to which he was then subjected; that he was perfectly ready to take
all the chances of an operation, and he knew there were many against him;
and that if he could be relieved by it he was willing to live out his ap-
pointed time, but if not, would rather die than hold existence accompanied
with the pain and misery which he then endured.

After he had finished his breakfast, I administered to him some medi-
cine: he then inquired at what hour the operation would be performed. I
mentioned the hour of eleven. He said, “ Very well; do you wish me
now for any other purpose, or may I lay down and go to sleep?” I was a
good deal surprised at this question, but told him that if he could sleep it
would be very desirable. He immediately placed himself upon the bed
and fell into a profound sleep, and continued so until I was obliged to rouse
him for the operation.

He exhibited the same fortitude, scarcely uttering a murmur throughout
the whole procedure, which, from the peculiar nature of his complaint,
Was necessarily tedious.

Chief Justice Marshall survived this operation some years, and finally
died of a disease of an entirely different character. Previously to his death
he laboured under very unpleasant symptoms, which are frequently met
with in advanced life; and in consequence of these, an erroneous rumour
was widely disseminated that he had a recurrence of his old complaint,
stone in the bladder.*

I should state, that at an early period after Judge Marshall’s case, the
operation of lithotripsy was introduced into this country. Dr. Physick
became convinced of the extraordinary advantages which it possessed over
lithotomy, and yielded it the full support of his sanction and approbation.

Among other contributions made by Dr. Physick to the department of
surgery, I should mention that we are indebted to him for making us ac-
quainted with the existence of preternatural pouches, or sacs, situated at
the lower extremity of the rectum, just above the verge of the anus. This
form of disease, which is one of not' unfrequent occurrence, is in many
instances productive of the most severe and distressing symptoms; so much
- so, that we have known patients labouring under it declare that iheir lives
were scarcely supportable. The complaint is rendered more perplexing
also from the almost uniform absence of all visible or external signs by
which it may be designated. It is only by a peculiar mode of examina-
tion that its existence can be detected.

Those who wish to acquaint themselves more particularly with this dis-
ease, 1 refer to the “ American Cyclopedia of Practical Medicine and Sur-
gery,” edited by Dr. Hays; in which is published, under the head of Anus,
a most able article, written by my friend Dr. Reynell Coates, giving a mi-

* See the No. for August, 1836, p. 534, for the correction of this rumour.

125

Memoir of Dr. Physick.

nute and correct account of the nature and treatment of these preternatural
pouches, as collected from Dr. Physick himself.

Before concluding the account of Dr. Physick’s labours, I may state,
that in a conversation with his relative. Dr. R. R. Dorsey, a short time
since, he recalled to my remembrance the case of a gentleman aged 70,
in which Dr. Physick had been eminently successful in alleviating, by-
means of a novel contrivance, the sufferings of a patient labouring under
an enlargement of the prostate gland. As Dr. Dorsey attended this patient
in conjunction with Dr. Physick, and had a particular knowledge of his
method of procedure, I requested him to furnish me with an account of
the case. He kindly acceded to my wishes, and sent me the following:

“The end of a small flexible catheter was introduced nearly to the bottom of
a very thin sac or pouch, three inches long, and an inch and a half in diameter
at the mouth. The edges of the sac, which was prepared from the intestine of
a sheep, were secured to the catheter by a fine silk thread, wrapped around it
with great care; and the material being as fine as the thinnest blotting paper,
adapted itself, when oiled, so closely to the instrument, that the bulk of the
whole was less than that of a large sized bougie.

“ After its introduction into the bladder, the membrane was injected with tepid
water, and the mouth of the catheter being stopped with a peg, it was gently,
but with some firmness, retracted. The consequent pressure at the seat of dis-
ease, gentle and uniform, and from the nature of the material used, as little irri-
tating as possible, had the happiest effect in repressing the enlarged lobe of the
gland; and afforded for many months, great relief by facilitating the discharge
of the urine. Although the patient took a severe cold immediately after the
operation, he did not suffer more than he had previously; and on recovering from
its temporary influence, he experienced a relief long unknown. The introduc-
tion of the instrument was again practised after an interval of some months,
with great advantage.

“ Much nicety is requisite in securing the edges around the catheter, so that
there may be no roughness to cause irritation during its retraction. It was also
deemed proper to wind the end of the thread loosely round the catheter and se-
cure it to the stopper. The material employed was prepared and may be pro-
cured in France.”

Dr. Physick informed me that he had been equall)^ successful in re-
lieving another case by means of the same contrivance.

In November, 1836, he was elected an honorary fellow of the Royal
Medical and Chirurgical Society of London. The conferring of this
honour was a full acknowledgment of his exalted merits, and justly ac-
quired reputation, and he did not affect to conceal the high gratification
which he derived from it. '

I have mentioned in the former part of this memoir, that the first case
recorded in his private journal is one in which he performed the extraction
of the crystalline lens. By a singular coincidence, it happened that the
last operation ever performed by Dr. Physick was for cataract, and took
place but a few months previously to his death. He, however, never saw
his patient after completing the process; the attack which terminated
his existence occurring on the afternoon of the same day.

I ought to mention, by way of apology for his engaging in any surgical op-
eration whilst labouring under such feeble health, that the circumstances at-
tending this case were exceedingly peculiar. The applicant was a foreigner.
Dr. Physick had operated upon his eye a year previously, and the gen-
tleman had remained in this city during a whole year for the purpose of
having it repeated by him. He consequently felt it incumbent upon him

11*

126

Biography

not to disappoint his patient; and he was not the man to shrink from the
performance of what he believed to be his duty, notwithstanding, as he in-
formed me, he was well aware that death was impatiently waiting for his
victim.

This operation was performed on the 13th of August, 1837. I was
present and watched him with the most intense anxiety. He was quite
collected and firm, and his hand was steady, though he was labouring
under great mental and physical suffering. Whilst witnessing this effort
in the cause of afflicted humanity, I felt a melancholy conviction that it
would be the final act of his professional life.

From this period his complaint went on increasing in intensity and vio-
lence. The symptoms of hydrothorax became developed to a most pain-
ful extent, and he suffered extreme agony from oppression at his chest and
difficulty of breathing; so much so, that sometimes he became unable to
lie down in his bed for whole nights together, but was obliged to stand
upon the floor, supported by assistants. In consequence of his increasing
illness, his old and well tried friend and associate. Professor Chapman,
was requested to visit him in consultation with myself. His malady,
however, had become uncontrollable, and it resisted the most strenuous
efforts that professional skill and affectionate attention could exert.

Some time previously to his death, anasarca took place; and in conse-
quence of his remaining so much in the erect position, his lower extremi-
ties became enormously swollen and distended with serum. The integu-
ments at length gave way, and openings formed, which finally ulcerated
and became gangrenous.

The Father of American Surgery expired without a struggle, on the
morning of the 15th of December, 1837, at twenty minutes past 8 o’clock.

“ He gave his honours to the world again,

His blessed part to heaven, and slept in peace.”

To the preceding account of the professional labours of Doctor Physick,
I have but little to add respecting his private life and character. It is in
fact rendered less necessary for me to dwell upon this point in his history,
inasmuch as in the several obituary notices of him which have appeared
from different sources, ample justice has been accorded to him both as a
man and a citizen. It is with feelings of the most sincere gratification
that I proceed to mention the following eulogies which were pronounced
subsequently to the demise of Dr. Physick; all of them expressive of the
deep sense which was entertained of his profound acquirements and per-
sonal qualifications.

“ A comprehensive minute, commemorative of Philip Syng Physick,
M. D., Emeritus Professor of Anatomy and Surgery in the University of
Pennsylvania,” was prepared, under the instructions of the Board of Trus-
tees of the University, by William Meredith, Esq. This is replete with
sentiments which fully comply with the resolution of the Board, “ That a
committee be appointed to prepare and present, at the next meeting of
this Board, a comprehensive minute; to state the long connection of the
deceased with this University, and to express the respect entertained for
his able and faithful services as a teacher, for his eminence as a practi-
tioner of medicine, and for the virtues which adorned his private charac-
ter.”

When the intelligence of Dr. Physick’s death was received at Louisville,

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Memoir of Dr. Physick,

“ resolutions were adopted by the faculty and class of the Louisville Medi-
cal Institute, to commemorate, by a discourse prepared for the purpose,
the invaluable services and character of the deceased.” The duty of pre-
paring this discourse devolved upon Professor Charles Caldwell, one of
the early friends and associates of Dr. Physick. He discharged the obli-
gations imposed upon him with his usual skill and ability; and delivered a
discourse highly gratifying to the friends and connections of Dr. Physick.

At the request of the American Philosophical Society, a Necrological
Notice of Dr. Physick was prepared, and presented at a meeting held in
May, 1838, by Professor Wm. E. Horner. From Professor Horner’s
long association with Dr. Physick in the chair of Anatomy, it will be con-
ceded that he possessed peculiar advantages for the successful accomplish-
ment of his task. It is well known, too, that he entertained an ardent af-
fection for Dr. Physick; and he has accordingly borne ample testimony to
his talents and acquirements.

We are also indebted to Professor Granville S. Pattison, of Jefferson
Medical College, for a highly laudatory notice of Dr. Physick, contained
in an introductory lecture delivered before his class, on the commence-
ment of the session of 1838-9.

It must be admitted that, by the community at large. Dr. Physick’s pri-
vate character was but imperfectly understood. This was owing to the
habits of perfect seclusion which he contracted, and to the slight inter-
course, other than professional, which he permitted himself to enjoy with
his fellow citizens. It must not be supposed, however, that this isolation
arose from moroseness of character or want of inclination to mingle with
society. A satisfactory explanation may be afforded by the entire self-
abandonment with which he devoted himself to his professional engage-
ments. This formed one of the most striking and remarkable points in
Dr. Physick’s character. History probably cannot show an example of a
more pure and absolute devotion to professional pursuits than he exhibited.

For the reasons just mentioned, he was supposed by some to be
stern and unfeeling, and wanting in the kinder sympathies of our na-
ture. There could not be a greater misapprehension. His feelings
were tender and susceptible in the extreme; and could those persons who
entertained an opposite opinion have been admitted to closer and more in-
timate relations with him, they would have acknowledged the great injus-
tice they had done him in such a surmise. Many instances might be cited,
were it expedient to occupy the necessary time, to illustrate Dr. Physick’s
extreme tenderness of feeling. At an early stage of his professional ca-
reer, he performed a few experiments upon living animals, with the
view of determining some physiological points. This formed a subject
of regret to him as long as he lived; and he could not divest his mind
of the idea that he had been guilty of a useless as well as wicked act of
cruelty.

Previously to his performing important surgical operations, his feelings
were so harrowed up, and he experienced so much anxiety, that it was the
custom of his family to endeavour to prevail upon him to execute such
operations as speedily as possible, in order to relieve his mind.

To those who only saw Dr. Physick as the bold and unflinching ope-
rator in surgery, his character might have appeared cold and unfeeling, and
they might have thought him,

“ Unlike to other men,

A snow-crown’d peak of science, towering high;”

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Memoir of Dr. Physick.

but to the few who knew him in his private circle the veil was withdrawn.
It w'as in the gentle charities of domestic life, as the tender and afi'ectionate
parent, or the sympathising friend, that his true character became revealed,
and his heart was felt to be keenly alive to the kindest and softest emotions
of which human nature is susceptible. He never appeared so happy as
when surrounded by his children and his family; and indeed I feel assured
that this formed one of the greatest consolations to him in the midst of his
protracted sufferings.

In his intercourse with his professional brethren Dr. Physick’s conduct
was regulated by the strictest principles of honour and integrity. When-
ever he was called in consultation with other physicians, without inquiring
how exalted or humble their positions might be, he was scrupulously care-
ful to avoid saying or doing any thing which could wound their feelings,
or prejudice them in the least in the estimation of their patients. He in-
variably staled his own opinions in a frank and manly manner, and was
ever willing to pay due deference to the opinions of others. Upon all oc-
casions he was happy and ready to confer upon his fellow practitioners the
benefit of his advice and experience, whether the information desired had
special relation to themselves, or to those under their charge. He was far
removed above the meanness of interfering with the patients of others;
and whenever he had it in his power to render a service to a younger
member of the profession, by a word of encouragement or commendation,
it was cheerfully bestowed.

It was impossible that a man possessed of a mind of so reflective and
contemplative a character as his, should not turn with anxious solicitude to
the doctrines of religion, and the contemplation of a future state. Religion
constituted, in fact, the most engrossing subject of attention during the lat-
ter years of his life-. How far he derived comfort and consolation from
his religious studies, it is not for me to say. I am very certain, however,
that a more pure and ardent seeker after divine truth I never knew. As an
observer of the principles of strict integrity and morality, I believe it will
be conceded that he was exemplary to a remarkable degree. He, however,
arrogated nothing to himself from this source. He expressed to me but a
short period previous to his death, that he possessed no merits of his own
o give him a claim to salvation. His humility and self abasement upon
the subject of religion were extreme; and he was always willing and ready
to apply to any source, however humble it might be, provided he thought
he could be enlightened and instructed by it.

His course of reading upon theology was very extensive; and unfortu-
nately for him he read many works of a conflicting and contradictory na-
ture. The effect of this upon one who had, during all his life, been in
search of indisputable evidences, was to create at times gloomy and de-
sponding views. Yet for very many years of his life he was in the uni-
form habit of perusing, every morning, a portion of the New Testament;
and when, in consequence of his illness and increasing infirmities, he was
incapable of so doing, his children were constantly employed in reading
this and other works of devotion to him. During his last illness he de-
rived great pleasure and satisfaction from the visits of his friend and pastor.
Dr. Delaney; whose kind attentions towards him were unremitting. I
feel assured that the hopes and promises of the Christian religion were the
greatest sources of consolation to him in the closing hours of his life, and '
smoothed his passage to the tomb.

129

REVIEWS.

Art. XII. Lectures on the Morbid Anatomy of the Serous and Mucous

Membranes. In two volumes. Vol. i. By Thomas Hodgkin, M.D.

London, 1836.

The situation of Dr. Hodgkin as Demonstrator of Morbid Anatomy
and Curator of the Museum at Guy’s Hospital, has rendered him emi-
nently qualified to lecture or to write upon the subject of Morbid Ana-
tomy.

The inspection of several hundred dead bodies, as he tells us, naturally
brought under his notice a great variety of morbid appearances in most of
the organs of the body; and in 1827 he began to lecture, commencing
with the morbid anatomy of the serous membranes, and in the following
year proceeding to parasitical animals; malignant diseases, and the mu-
cous membranes.

Our author bases the arrangement of his course upon general anatomy;
as he considers that it is only by collecting into one view the modifica-
tions produced by disease in any one tissue, that we can obtain accurate
knowledge of the relations of these morbid alterations to each others and
to the healthy state. He begins with the serous and mucous membranes,
because they are so generally diffused over the body, and because they
are so frequently affected with disease. In discussing the abnormal alter-
ations or conditions of these membranes, he adopts the following classifi-
cation.

Deviations from the normal state consisting in;

1. Deficiency.

a. The result of imperfect development.

b. Loss sustained.

2. In excess.

3. In form.

4. In appearances which may be regarded as the result of ordinary in-
flammation.

5. In appearances which are the result of scrofula.

6. In appearances which are the result of diseases termed malignant or
resembling them in structure.

7. In hydatids in the particular organ.

8. In the effect of accidental injury.

Dr. H. proposes to retain the word “ inflammation,” in preference to
“ hyperaemia,” notwithstanding its rejection by Andral, who remarks that
it is like a piece of money that has lost its stamp by wear, and has be-
come unfit for' further use. The old coin. Dr. H. remarks, may long con-
tinue much more convenient than the new, notwithstanding its indistinct-
ness, especially if the new coin I bear a different name and value. The
word hyperaemia, though sufficiently expressive of the presence of an
undue quantity of blood, is necessarily applicable to many cases distinct

130

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from inflammation, and at the same time is inapplicable to some states
that belong to the various stages and modes of inflammation. In this we
heartily concur with Dr. H. The abandonment of an old, well known
term, and the introduction of a new one, we consider always objection-
able and not to be admitted, unless for very strong reasons: for as there is
no general and supreme authority to fix such matters, the new term will
never come into universal use; and will only create confusion.

Medical literature is in much the same situation with one of our cities
or large towns; as long as the old name of a street is preserved, every
one knows where he is; but let it once receive a new name, and every re-
sident in it has some good objection to the one adopted, or some prefe-
rence to another, so that every successive year it receives a new designa-
nation.

Dr. H. makes a distinct division for the effects of scrofula, which though
closely allied to those of inflammation, have many distinguishing pecu-
liarities. In the sixth section, are included cancer, fungoid disease, and
melanosis, which present the remarkable character of depending on an
adventitious structure; which derives its growth and nourishment from
vascular connection with the parts in which it is situated; and is conse-
quently very difierent from the mere degeneration of natural structures.
With regard to hydatids, he considers them as parasitical animals; as they
have no vascular connection with the parts in which they are found, and
are rarely if ever found even mechanically attached to them; and they
have the wonderful power of reproducing their kind often to a very great
extent.

In his second lecture. Dr. Hodgkin proceeds to the general considera-
tion of the morbid anatomy of the serous membranes. These membranes
are the earliest developed in the embryo. According to some physiolo-
gists, the alimentary canal and the urinary bladder owe their origin to se-
rous membrane. They are also more frequent in their formation, nature
seeming to delight in the production of such membranes as the arachnoid,
the pleura, the pericardium, the peritoneum, and the tunica vaginalis.
The eye, the pulps by which the teeth are formed, and the synovial cap-
sules consist in part of serous membrane slightly modified. The large
extent of surface presented by these membranes, afford the best opportu-
nities for observing the varieties in the modes of inflammation.

The ultimate structure of the serous membrane is believed to consist
in extremely minute fibrillse combined so as to form lamellae. Dr. H.
affirms that the idea that these fibrillse are composed of globules arranged
like a string of beads, is founded entirely in an optical deception. He has
spent hours in the examination of this subject in company with Mr. Lis-
ter, the inventor of a very powerful microscope; and is perfectly con-
vinced of the fallacy of the globular theory. The perfectly formed mem-
branes, he thinks, without exception, consist of fibrillsB of tolerably even
size, bearing no resemblance to beads. The imperfectly formed mem-
branes answ'er the description given by Meckel. These membranes are
supplied with blood vessels and absorbents which are extremely minute
in the healthy state, but become preternaturally visible and distended when
inflammation causes an increased effusion in the former, or when the se-
cretion of the lymphatics is too abundant. The existence of nerves has
been denied by some. They become highly sensitive in disease, yet
active and fatal inflammation sometimes goes on in them with little or no

Hodgkin’s Lectures on Morbid Anatomy,

131

accompanying pain. They possess a considerable degree of extensibi-
lity and contractility, as is evinced in pregnancy and parturition, and in
the daily functions of the bladder and rectum. The microscopic obser-
vations of Mr. Lister and our author have convinced them that there is a
greater similarity between the fibres of the arterial and serous tissues,
than there is between either of them and the muscular.

Dr. H. considers that the serous and mucous membranes are transmu-
table into each other. The fluid secreted by the arachnoid is the most
aqueous of the serous secretions. Next are the waters in the membranes
of the ovum. The secretions from the ovum appear to be more charged
with animal matter. We find in the cellular membrane of particular parts,
close cavities which produce and contain a mucous secretion, and conduct
us to the synovial bursae and capsules, in which mucus obviously exists.
Hence the transition is easy to the mucous membranes of the eye, the
secretion of which is more allied to serous secretion, than that of most
portions of this tissue. In accidental productions of a natural or analo-
gous tissue so frequent in serous membranes, we find in some of the
cysts a perfectly clear, limpid, aqueous fluid; in others a straw coloured
serum; in others a fluid bearing the closest resemblance to synovia; .and
in a fourth class, a clear and perfect mucus. The serous membranes,
moreover, undergo certain changes, the result of which is to convert them
into mucous membrane. We do not find, however, in the physiological
conditions of the organs themselves, such clear evidence of the converti-
bility of the one into the other,, as has been offered with regard to the gra-
dations that exist between them. He has repeatedly found the secretions
of the pericardium glairy and bloody ropy from the quantity of mucus it
contained. He has found the surface of the pleura lubricated with a vis-
cid mucus which made the lungs feel as if smeared with saliva; and in
inflammation of the pericardium, this membrane covered with muco-puru-
lent effusion. In ovarian dropsies, which depend upon the development
of large adventitious cysts, the first fluid evacuated is frequently thin and
serous; that which is next drawn, is thick and loaded with mucus; and a
fourth or fifth puncture evacuates puriform matter.

The morbid appearances common to the serous membranes, are in the
first place suppression of secretion; the membranes becoming nearly or
entirely dry. Gas is sometimes secreted in the cavity of these mem-
branes. This is a rare phenomenon, and not to be confounded with ca-
daveric formations of gas. It is said to have been found between the
layers of the arachnoid, sometimes in the pericardium, and more fre-
quently in the peritoneum. These membranes may, through some altera-
tion in their functions secrete air; but it is more commonly produced by
chemical action taking place immediately after death. In this case it is
usually attended with a peculiar smell, and may, on examination, be de-
tected in other parts of the body. Excess of secretion, the fluid remain-
ing unaltered, is another morbid condition. This excess constitutes the
dropsies of the serous cavities, such as hydrocephalus, hydrothorax, hy-
drops pericardii, ascites, hydrocele, hydrarthus and ganglion. Altera-
tions take place in the quality of the secretions. They sometimes
acquire the character of mucus, are sometimes tinged with bile, and
occasionally with blood. The admixture with blood is as often cadaveric
as morbid. The confinement of this appearance to one cavity, the gene-
ral state of the body and its freedom from other cadaveric changes, will

132

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generally distinguish the morbid from the cadaveric. In many coses,
however, Dr. H. allows it is difficult, if not impossible, to draw the line.
Blood has been found in the pericardium where no rupture of the heart or
of any vessel was discoverable: not unfrequently in the pleura; often in
ascites mixed with the usual fluid; and in hydrocele when it is sometimes
pure, forming hsematocele. Chyle may possibly have been found in the
cavity of the peritoneum. That milk should be, is absurd and incredible.
A light coloured puriform inflammatory effusion has probably been mis-
taken for milk.

Deficiency of a whole or a part of the more important serous membranes
is rare, except in cases of deficiency of the parts with which they are in
contact. Thus in acephalous foetuses, the arachnoid must of course be
wanting. The anterior part of the peritoneum, and the corresponding
parietes, have sometimes been wanting, leaving the abdomen open. In
these instances, in which the testes have not descended into the scrotum,
the reflected portion of the tunica vaginalis is wanting.

Excess is more frequent. It may consist in the prolongation of normal
membranes, such as occurs in the arachnoid in congenital protrusions of
the brain; in the pleura, in which are sometimes formed appendices, giving
a covering to collections of air or fat; in the pericardium and the synovial
capsules, where similar appendices are sometimes formed; in the perito-
neum, where these prolongations are most frequent and remarkable; in all
cases of hernia, congenital excepted; and in the tunica vaginalis. Excess
may consist also in the formation of new cavities.

Effects of Inflammation. These are the most common and the most
important alterations to which these membranes are subject, and naturally
occupy a large part of the attention of our author. The earliest effect of
inflammation is the suppression of the secretion, leaving the membrane dry;
a state which does not long continue, and can therefore be seldom witness-
ed on dissection. As the irritation subsides, transpiration returns; but if
the inflammation has been violent, the serum exhaled does not possess the
usual qualities. It becomes, in most cases, superabundant in quantity, and
is mixed with some more solid material, giving rise to various forms of false
membrane, and often rendering the fluid more or less turbid and opaque.
Villerme considers the false membrane to be always the result of inflam-
mation. He regards them as the matter of suppuration thickened and con-
creted. Where false membrane is not found after death, in persons sup-
posed to have died of pleurisy, inflammation of the muscles must, in most
cases, have been mistaken for it. According to Villerme, an indvidual
may die after exhibiting all the marks of pleuritis, and no trace be found
on inspection. Dr. H. has never met with an instance in which some
marks of inflammation were not to be found. Where the patient has died
upon the second or third day, no false membrane may be formed; but there
is generally an effusion of sanguineous or puriform serum. In a few in-
stances, he has found an effusion nearly or quite transparent, which, on
removal from the body, possessed, though in a feebler degree, the coagu-
lating power of the blood.

Dr. Hodgkin does not agree with Dupuytren, Villerme, and Sir Everard
Home, in regard to the formation of the false membranes. He differs from
them with regard to the organisable properties of pus or puriform fluid.
This he believes to be always more or less excrementitious; and where an
outlet from the body is not afforded, it retards the cure by interfering with

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Hodgkin’s Lectures on Morbid Anatomy.

the organisation of other substances formed at the same time, particularly
the coagulating effusion noticed above. This, which is the coagulable
lymph of John Hunter, is the most eminently plastic effusion, and as co-
agulation advances, it throws out tende- diaphanous films, which are found
separated by, and infiltrated with, a limpid and often straw-coloured serum.
These false membranes are not opaque and cribriform, but continuous and
transparent; a condition which militates against the idea of Villerme, who
considers them produced by the aggregation of an infinite number of
minute fiocculi.

There is another form of effusion which is not plastic. It consists of
whitish opaque particles diffused through the serum, which, when com-
bined with the more plastic effusion, either renders it uniformly opaque
and of feeble cohesion, or sprinkles it with opaque points, or with puriform
or tuberculous matter. It differs principally from the plastic effusion, by
its entire or nearly total want of vitality. False membranes possessed of
this character are a constant source of irritation. The false membrane may
itself become a secreting organ, sbmetimes yielding a particled puriform
fluid, sometimes more plastic lymph, which may assume the most perfect
membranous appearance, even when the first formed membrane is loaded
with opaque matter. When the latter is more organisable, if it be not too
much irritated by the inorganisable matter which it has produced, it even-
tually takes up as much of it as is capable of absorption, and shuts up the
remainder in a cyst such as forms around a bullet or other foreign body;
the opaque albuminous part being incapable of absorption.

In regard to the manner in which the false membrane becomes supplied
with vessels. Dr. H. justly observes that the idea of a real generation of
vessels is so repugnant to all our present notions with regard to the circu-
lation, that it cannot be admitted; although red vessels are first seen in the
false membranes, without our being able to trace any connection. The
other theory, that these false membranes are the bed into which the exha-
lent vessels extend themselves, is more probable, and is supported by the
fact that injections may be thrown into them from the neighbouring vessels.
Dr. H. conceives that, at the inflamed part, the minute blood vessels not
merely become distended, but that their delicate parietes, and the structure
through which they ramify, become softened, and yielding to the pressure
of the blood in the distended vessels, give way in numerous points. The
very small quantity of blood thus permitted to escape, is not diffused, but
is received into the false membrane, appearing in spots which soon assume
a dendritic appearance, and, extending in length, become vessels. They
are at first feeble and distended, and therefore larger than those from which
they proceed, and hence the redness of newly formed membranes; but they
afterwards contract and become nearly or quite invisible. The uniformity
of size, and the straight and parallel course of the vessels in newly formed
false membranes, give them the appearance of muscular fibres.

Where the effused material is most abundant, organisation is most difficult.
The surface of the effusion first becomes consolidated, and thus shuts out
the internal part from the rest of the cavity; and this, if its organisation does
not proceed, becomes converted into pus, and may be gradually absorbed.

When the adhesions produced by the matter effused are not universal,
and the motion between the serous surfaces is considerable, lengthened
bridles are sometimes formed. Sometimes a delicate false membrane, the
product of a highly plastic inflammation, is raised by the serum between it
No. XLYII.—May, 1839. 12

134

Reviews,

and the original serous membrane, so as to produce bladders or cysts of
various sizes and shapes, sometimes resembling clusters of grapes, in which
slate they have been mistaken for hydatids. Sometimes they become cylin-
drical, and form a cul desac. 4'he production of false membrane in the form
of cyst, occurs most frequently in the peritoneum. Detached bodies are
sometimes found in the cavity of a serous membrane, formed, as Dr. H.
supposes, from an isolated clot of coagulable lymph, which, in process of
time, acquires a lirm and membranous surface. In the soft and recent state,
these are of the size and figure of an egg plum, but in the firm and ad-
vanced stage, not larger than a pea or a marble.

There is another form of false membrane, which is from the first more
adherent to the serous surface than either the very recent membranous
films, or the opaque inorganisable flocculi. It has a firm and dense struc- '
tore, does not become even visibly vascular, and presents an uneven, unat-
tached, sometimes scabrous surface, towards the interior of the cavity. In-
flammation, it is probable, may be set up at successive periods, in different
parts of the same serous membrane.

When inflammation has attacked any of these tissues, it has a strong
tendency to spread. 'I’his is most conspicuous where the inflammation is
idiopathic; but in cases of injury, the inflammation is more frequently limit-
ed to the neighbourhood of the lesion, particularly if both surfaces of the
membrane are injured. If a patient have recovered from a wound in the
thorax, by which both pleura costalis and pleura pulmonalis have been in-
jured, the pleuritic effusion will probably be found confined to the imme-
diate vicinity of the wound. Wounds of the dura mater, which open into
the cavity of the arachnoid, are attended with very great danger, being liable
to produce inflammation of that membrane to a very great extent. Yet,
when the injury has been greater, extending through the membrane into the
brain, and even producing a loss of substance in this organ, the symptoms
are comparatively slight. Hence the late Henry Cline, Jr. suggested the
propriety of designedly lacerating the arachnoid and pia mater, in cases
where the dura mater had alone been wounded.

The false membranes have a tendency alter a time to become hardened
and coiitracted, and lose their vascularity. 'J’hey become narrower, form-
ing bridles, which in time may be separated by a natural process. 'J'o this
contraction of tlie false membranes. Dr. H. attrib ites the remarkable retro-
cession of the chest in a patient who recovers from empyema. In persons
affected with jaundice, these membranes are tinged with yellow.

When the effusion has been small in quantity, much diffused, and of the
most plastic quality, it ultimately becomes a loose cellular web. When
the quantity has been greater, and the inflammation protracted nd chronic,
very piobably from the admixture of opaque particles, the form ultimately
assumed is dense and semicartilaginous.

Pressure diminishes the amount of the fluid secreted. Thus when the
lung is inflamed at the same lime with the pleura, the lung does not be-
come collapsed, as after cases of simple pleurisy; and we find the solid
product of inflammation abundant, while the serum seems to be nearly or
entirely absent.

Serous infiltration of the cellular tissue is very common, and is more
frequent and remarkable where the membranes are thin, hence the best ex-
amples of it are seen in the arachnoid and in the tunica vaginalis. The

135

Hodgkin’s Lectures on Morbid Anatomy,

swelling of the scrotum from/mfiltration of the cellular membrane is a well
known consequence of the injection for the radical cure of hydrocele.

The formation of bony plates beneath tlie serous membranes is a frequent
occurrence, as the material there effused has a tendency to become dense
and hardened, the covering afforded by the membrane favouring the depo-
sition of bony matter. The opposite state, in which the effusion is more
or less puriform and wddely diffused, and the cellular structure very lacera-
ble, is found in conjunction with the turbid and puriform effusion into the
cavity of the serous membrane.

The subserous cellular membrane is sometimes itself primitively affected.
It affords the bed in which commence those adventitious deposits described
as steatoma, cancer, tubercles, hydatids, and scrofulous, fungoid, and
melanoid tumours.

Gangrene is extremely rare, especially in idiopathic inflammation.

The effects of scrofula are not confined to the production of distinct col-
lections of a scrofulous deposit in the cellular membrane, or the attached
surface of the serous. Collections of tuberculous or scrofulous matter are
sometimes found on the smooth unattached surface. 'The varieties of ma-
lignant disease are almost exclusively confined to the subserous cellular
membrane; yet we may occasionally find minute bodies .having the cha-
racter of scirrhus, in the substance of serous membranes, in individuals
known to be tlm subjects of malignant disease. The presence of hyda-
tids in the serous cavities must be looked upon as wholly accidental, the
consequence of their escape from the seat of their formation.

Wounds penetrating these cavities are apt to develope a form of inflam-
mation which is characterised by the want of plasticity of its effusion.

It is rare for one serous membrane to communicate its inflammation to
another in its immediate neighbourhood. Traces of inflammation, how-
ever, are often found concurrently at the base of the right lung and on the
convex surface of the liver. The same thing is observable, though less
frequently, with respect to the left pleura and the peritoneum in the neigh-
bourhood of the spleen. Tlie serous membranes are united by an inexpli-
cable but indubitable sympathy. Thus in rheumatism, the inflammation
of the synovial membranes is often followed by pericarditis. At other
times it is the pleura that is thus affected. Dr. Foville has seen articular
rheumatism subside upon the sudden production of hydrocele, and again,
a return of the rheumatism upon the cure of the tumour. That species of
inflammation of the kidney which lias been described by Dr. Bright is ac-
companied by a general tendency to disease of the serous membranes. A
proof of the morbid sympathy existing between the serous membranes
may also be seen when they are affected with cancerous or fungoid tuber-
cles. When growths of this kind have been formed about the peritoneum,
there is not unfrequenlly found a sprinkling of the same kind about the
pleura; and sometimes, thougli more rarely, about the pericardium.

We have thus given a pretty full abstract of our author’s second lecture,
which may be considered as a summary of the contents of the volume,
particularly so far as relates to normal serous membranes. He next pro-
ceeds to the consideration of each membrane and the alterations produced
by disease, treating of these alterations according to the arrangement given
in the table. The third lecture is occupied with the Arachnoid.

Dr. H. divides this membrane into four portions, the alterations of each
of which he discusses separately. The first portion is that which is ex-

136

Reviews.

ternal to the brain. The second, that which lines the ventricles. The
third is the portion which belongs to the plexus choroides. The fourth is
that of the spinal chord.

First portion. — The product of inflammation here, is more frequently
purely serous than elsewhere. Dr. H. has seen only one instance of pu-
riform secretion or false membrane between the polished surfaces of the
arachnoid, and in this case the inflammation appeared to depend upon a
local cause; the irritation excited by a lumbar abscess which communicated
with the spinal chord. Dr. H. thinks such effusion may take place with-
out external cause. As a consequence of injury, it is not uncommon. —
Adhesions between the two surfaces are very rare; but sometimes met
with, particularly after some cause of local irritation, such as tumours or in-
juries of the head.

The results of inflammation on the attached surface, especially that in
contact with the pia mater, are as frequent as they are rare on the polished
surface. “ It is in this situation we are accustomed to look for and find,
pathological appearances, in those cases of acute disease which are marked
by a high degree of fever, by pain of head, delirium, convulsions, and
often ultimately by coma; symptoms, which in children aro recognised as
indicative of acute hydrocephalus; and in adults, of brain fever, phrenitis or
rather meningitis, if the practitioner be acquainted with modern pathology.

After the most active symptoms of arachnitis we often find nothing but
serum infiltrated behind the arachnoid; but we sometimes meet with a co-
agulable and more frequently a puriform effusion. In almost every case
of arachnitis the membrane becofnes thickened. A large quantity of serum
is sometimes found beneath the arachnoid covering the brain, in cases
where the inflammation, if any, must have been of a very chronic cha-
racter. Ossific deposits are rarely found beneath the arachnoid investing
the brain, but they are often found between this membrane and the dura
mater lining the cranium. Fungoid tumours are sometimes formed in the
pia mater, of the size of a cob nut, producing a corresponding depression
upon the surface of the brain, which does not appear otherwise affected.
In other cases, the brain has participated in the disease.

Second division. — Arachnoid lining the ventricles. “This membrane
may be the seat of either acute or chronic inflammation. In both of these
states, there is often a copious effusion of a purely serous character, con-
stituting either acute or chronic hydrocephalus internus, in the same
manner that the serous effusion under the arachnoid covering the convolu-
tions constitutes hydrocephalus externus. This is the most frequent effect
of arachnitis affecting that part which lines the ventricles; and in conjunc-
tion with this effusion, the membrane becomes thickened, semitransparent,
pulpy, and sometimes sprinkled with minute spots of blood.”

It is rare to find flakes of recent coagulating lymph in this situation, but
we sometimes meet with old adhesions. The inflammatory effusion is
sometimes of a non-plastic character assuming the appearance of a thin
sero-purulent fluid. The surface of the membrane is occasionally sprinkled
with very minute and tolerably firm elevations, resembling finely powder-
ed glass.

Third position. — Arachnoid of the Plexus Choroides. When serous
effusion takes place here, it is generally collected into small cysts, which
give to the plexus an appearance like that of a bunch of currants. They
vary in size from that of a millet seed to the diameter of a third of an inch.

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Hodgkin’s Lectures on Morbid Anatomy.

The plexus occasionally exhibits numerous opaque whitish spots diffused
through its whole length. It is, however, more common to find the effused
matter collected at a particular spot, which is generally near the com-
mencement of the descending cornu. This has sometimes occurred on
both sides, forming a well defined tumour as large as a barbary-berry, or
even a horse bean. These bodies are sometimes soft, but they are liable
to become loaded with earthy matter, giving them the character of petri-
factions. The plexus is sometimes found extremely exsanguineous and
pale, even when there has been much cerebral excitement.

The cerebral arachnoid is liable to effusions of blood either spontaneous
or from violence. The possibility of these effusions, Dr. H. considers a
sufficient answer to those who doubt the existence of a lining membrane to
the dura mater. He gives a case in which it occurred at Guy’s Hospital.
The production of scrofulous tubercles, and the development of fungoid
tumours, he considers additional proofs, if any were wanting. Fungoid
tumours formed on the attached surface, not merely raise the membrane and
demonstrate its existence, they sometimes occasion the absorption of the
dura mater, and ultimately the cranium, so as to protrude externally.

Fourth division.-^ k.. of the Spinal chord. This Dr. H. tells us has
been found by Dr. Sharpey, to consist of four layers; one being the dura-
matral sheath; one investing the chord itself; and two layers within these,
so closely applied, and in general so thin and diaphanous, as to appear but
a single membrane. The cellular membrane of the arachnoid which forms
the pia-matral covering of the medulla, is less vascular and less loose and
abundant, than that of the brain, but closely resembles that covering the
pons varolii and medulla oblongata, with which it is continuous. Conge-
nital deficiency of this membrane seldom or never occurs. An example of
its excess is found in spina bifida.

Inflammation of the spinal arachnoid is not rare, but the patient seldom
dies at a period sufficiently early, to allow of the inspection of recent al-
terations. The fluid effused, even when the result of inflammation, is
more frequently serous than puriforra. A small quantity of lymph may
sometimes accompany it, as is proved by the old adhesions not unlrequent-
ly met with.

The thickening and contraction of the spinal arachnoid, Dr. H. con-
siders as an occasional cause of paraplegia, wliich will be more or less
complete, according to the amount of compression exercised on the spinal
chord. When the case is not an extreme one, progressive improvement
may take place, both by the chord becoming accustomed to the pressure,
and by the slow and partial absorption of the adventitious deposit within
the membrane. To this cause, he attributes the gradual improvement
sometimes witnessed in paraplegia; and adds a caution against the per-
severance in very active measures of treatment, such as copious local
depletion, deep and extensive issues, &c.; which may increase the dan-
gerous sloughing of parts exposed to pressure, while deprived of their
ordinary degree of innervation.

When the membrane has been injured by violence or excessive cold,
the spinal chord itself is sometimes softened, or its cineritious substance
is unusually injected, sometimes it presents a vermiform or annulated ap-
pearance, which may be attributed either to the compression of the con-
tracted arachnoid, to the turgescence of the afi'ected part of the chord, or
to both causes combined.

12*

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Small patches of bony or cartilaginous matter are sometimes found
about the chord, from the size of a pin’s head to that of the finger nail
or more, and varying in thickness from that of a peppercorn to a melon
seed. These spots are frequently met with in tetanus, fatal chorea, and
other diseases in which the spine has been supposed affected, and they
have been considered a cause. They are however not always found in
such cases; and they have been found in subjects, where these symp-
toms were wanting. Dr. H. regards them, however, as undoubtedly mor-
bid secretions, and as indications of such a want of integrity in the chord
as may predispose to tetanus, chorea and the like affections.

The pericardium forms the subject of the fourth lecture. This Dr. H.
remarks, forms one of the best examples of a serous membrane. It is
rarely deficient, most cases of its supposed absence being probably merely
cases of pericarditis terminating in its close and universal adhesion, but two
undoubted instances are recorded, one by Dr. Baillie, and the other by Bres-
chet. He knows of no example of congenital redundancy, unless the bridles
and membranous bands which unite its two surfaces are congenital; an
opinion held by Tioch and others, but to which our author does not in-
cline. It is preternalurally increased in size, in hypertrophy of the heart,
in cases of inflammatory or hydropic effusion, and from the development
of tumours. The effects of inflammation are such as belong to the serous
membranes generally. Its secretion is often preternaturally increased,
forming hydrops pericardii, which may, in general, be distinguished from
pericarditis, by the presence, in the latter, of a few films of false mem-
brane. These two diseases have a tendency to pass into each other. Dr.
H. thinks that pericarditis is much more common and much less dan-
gerous than has hitherto been supposed. When the quality as well as
the quantity of the fluid effused is altered, we have either coagulable
lymph or an effusion of a more puriform character. The former leads
to the formation of the most perfect cellular adhesions. The surfaces of
the close and reflected portions, sometimes become so intimately united
as to give rise to the opinion above alluded to of the absence of the peri-
cardium. In other cases, the adhesion is looser. In a third variety, it is
formed of a multitude of filaments. In a fourth, by broad and membra-
nous layers. Bridles of adhesion connecting the opposed surfaces are
common. Our author thinks that adhesions are correctly considered as
always the result of inflammation. When there is much non-plastic mat-
ter effused, their production is prevented; in which case the surface of
the heart is not unfrequently covered with long shaggy, soft, and very
feebly organized villi. It is this appearance that has given rise to the
improbable stories of the heart being found covered with hair. In other
cases, in which adhesion is prevented, the surface of the false membrane
presents a reticulated appearance which has been compared to the bon-
net or second stomach of a calf. When the matter is of the most inor-
ganizable kind, it has a puriform appearance.

The pericardium is apparently more prone than any other serous mem-
brane to assume the scabrous appearance, spoken of above. Plates of
bony matter are apt to form upon the attached surface, and when exten-
sive, it has been erroneously described as ossification of the heart. The
opaque white patches which are often found upon the surface of the
heart, our author considers as the result of pressure; that of an uneven
and remarkably indurated liver, for example: or a bony deposit beneath

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Hodgkin’s Lectures on Morbid Anatomy,

the reflected pericardium. The motions of the heart aid the effects of
pressure in producing these appearauces. Traumatic pericarditis is of
course very rare. Dr. H. refers to one case, mentioned by Dr. Ferrus.
Gangrene is extremely rare. Bloody spots are sometimes found, and are
the effect of purpura rather than inflammation. Scrofulous tubercles are
very uncommon. Tumours are, perhaps, sometimes, though not often
met with. Acephalocyst hydatids have been found between the close
pericardium and the substance of the heart. In one specimen, presented
to Guy^s Museum, there were acephalocysts of various sizes, sufficient
to fill a quart measure. The sac containing them was situated in part,
beneath the close pericardium, and in part beneath the pleura pulmonalis
of the right side.

Lecture fifth embraces the morbid conditions of the pleura. The in-
flammatory effusion here often assumes a semi-cartilaginous appearance,
especially when the inflammation is chronic, which it is liable to become
when the fluid part of the effusion is not absorbed, or when organization
is retarded by the presence of non-plastic matter. When this matter is
very abundant and diffused through the fluid, in the form of minute par-
ticles, it constitutes empyema — a term now generally restricted to the
collection of a puriform fluid in the cavity of one of the pleurae.

Our author proceeds to a full and interesting discussion of the subject of
empyema. He observes that the most favourable termination of chronic
pleuritis consists in the contraction of the chest; which often takes place
notwithstanding the presence of a considerable quantity of inorganizable
matter, which remains after the serum is absorbed or removed. This
matter is shut up in a cyst or envelope, and sometimes acquires a bony
structure. It is the contraction of this new membrane, rather than the
absorption of fluid, which causes the contraction of the chest that ensues
to a remarkable degree, while it had hitherto been preternaturally distend-
ed. The fluid of empyema is sometimes evacuated by a process called
empyema of necessity, in which a spontaneous opening is formed. Dr.
H. thinks that this process is conducted in a manner more common in the
peritoneum. When a considerable quantity of inorganizable matter has
collected, ulceration takes place in that part of the serous membrane, with
which it is in contact; and by a continuation of the same process, the ex-
ternal opening is effected. This supposition of our author is the more
probable, because this process resembles that generally employed to re-
move a foreign substance from the body; and it is in this light, that the
inorganizable matter must be considered.

His remarks upon the method of making the opening for the escape of
the fluid of empyema, are worthy of attention. Where the operation is
not urgent, he prefers the use of caustic to that of the knife or trocar;
because, in the first place, this method resembles the process of nature
above described; and, secondly, because strong external irritation is one
of the most powerful means of promoting absorption. Whilst we are
preparing for the escape of the effusion, we are giving nature the best
chance of removing it herself, arid we perhaps may find that before an
opening is effected, the plan may be changed, and the cure completed by
one or more additional cauteries. The use of the trocar may be resorted
to subsequently, if it should be necessary, and with greater probability
of a favourable result; since the cavity is found in some degree prepared
for the opening, whereas it is taken by surprise, when the trocar is first

140

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used. Dr. H. mentions an instrument, contrived by Dr. T. Davies, for
making an experimental opening of the chest. It consists in a needle-
pointed stilet, which gradually increasing in size, becomes, at its thickest
part, of the size of a crow-quill.

The fluid of empyema sometimes finds an exit, by a communication be-
tween the cavity in which it is seated, and the bronchial tubes. This pro-
duces one of the most frequent forms of pneumo-thorax, and it is, in these
cases, that the stethoscopic sound called “ metallic tinkling” occurs. For
the production of this symptom, there should be not only a large cavity
containing both air and a liquid, but likewise, a communication between
this cavity and the air tubes. It takes place also in those cases of phthi-
sis, where a large portion of the lung is excavated.

Dr. H. describes a particular appearance of the pleura which occurs
when the matter deposited by chronic inflammation has assumed a close,
compact, and almost semi-cartilaginous character. It is produced, as he
supposes, by the presence of a soft, yet concrete and inorganizable ma-
terial, which interferes with the organization of the false membrane, and
hence produces depressions in it, giving it a worm-eaten appearance, re-
sembling the efiect of ulceration. This material is easily removable, leav-
ing a clean and well defined margin and surface to the depression which
it has occupied.

In the sixth lecture the peritoneum, tunica vaginalis, and bursae are
considered. Dr. Hodgkin discusses, as in the other membranes, the de-
gree of proneness of this to deflciency or excess; the alterations of its se-
cretions and the effects of inflammation. He describes a circumstance
not jiariicularly noticed by other authors, the formation of false parietes
from excess of plastic matter. This false membrane is firmly united to
the intestines, dipping down between their evolutions; presenting an even
surface to the parietes, and remaining unattached to them, except at the
margin of the layer formed by the adventitious deposit. He relates a
case in which this formation occurred.

A peculiar result of inflammation is met witl^ occasionally, which is
confined to the surfaces of the liver and spleen. It consists in a very re-
markable semicartilaginous thickening, interrupted by spots of a circular
figure and small size, at which the thickening is either very inconsiderable
or IS wholly wanting; they may be either distinct or confluent. The sur-
face so affected has a honey-comb or worm-eaten appearance, like that
noticed in the pleura. Dr. H. has seen two cases in which the free sur-
face of the peritoneum appeared to be deranged by malignant disease.
Detached secretions of a rounded figure and semicartilaginous or bony
form are met with occasionally.

Within the synovial capsules loose bodies are sometimes found which
Dupuytren supposed to be hydatids. Our author believes them to owe
their origin and form to the obstacles which even the most plastic inflam-
mation must find to the production of adhesions. The most violent con-
stitutional irritation has followed a puncture for the removal of these bodies.

The dropsy of the serous cavities would seem from the observations of
our author to be more frequently the result of inflammation of these mem-
branes than other recent writers suppose. Disease of the heart or lungs,
disease of the liver wdth obstruction, Bright’s disease of the kidneys, may
be occasionally causes of ascites, but one of the most common causes, he
says, is exposure to cold. Although the effusion may have commenced

Hodgkin’s Lectures on Morbid Anatomy, 141

independently of inflammation, the effused fluid is very likely to set it up
in a chronic form.

The seventh lecture is occupied with a digression upon the subject of
parasitical animals. This might seem rather out of place in connection
with the serous membranes, particularly as it includes those which infest
the intestines. Our author, however, conceives this to be necessary be-
fore proceeding to the abnormal serous membranes, which come next in
order, because the adventitious serous cysts have so generally been con-
founded with hydatids. Dr. Hodgkin considers hydatids as parasitic anU
mals, because they are found living distinct and unsupported by any con-
nection with the organs in which they are met with. They also have the
peculiarity of producing each other. The natural cure of hydatids is ef-
fected by the formation of a communication between the cyst containing
the hydatids and either the surface of the body, the intestinal canal, the
bladder, or some other cavity that has an external outlet. In other cases
the animal dies, its fluid is absorbed, and its membrane is folded and shut
up as an inert body within the outer cyst, which contracts upon it. Their
death is occasionally followed by an abscess. Dr. H. thinks that cures
might undoubtedly be effected by art. Some remarkable cases appear
to have been treated with success by Dr. Recamier. He suggests the
trial of acupuncture or electropuncture. From the effect of turpentine and
of Deppel’s oil as anthelmintics he thinks them worthy of trial internally
and externally. Saline purgatives have sometimes caused their evacua-
tion. When they are abundant in different parts of the body, their death
is not desirable, as the irritation produced by the presence of so many
inert bodies, must be attended with serious consequences. Our author
notices the trichina spiralis, a little worm affecting the muscles of voluntary
motion, which has been recently discovered. Richard Owen, by whom
it was first observed, considered it allied to the eels found in paste and
vinegar. Dr. H. adopts the theory of the existence of seminal animal-
cules, which has been disputed, and admits the possibility of spontaneous
generation. In these two points we cannot agree with him. The latter
seems to be somewhat involved in the former, and in the separate exist-
ence of hydatids. It is easy to conceive that the eggs of those animals
that are found in the intestines are introduced into the system in various
ways, but the hydatids, if animals, seem to be viviparous, not oviparous;
and at any rate, they are found in parts of the body to which there is no
external inlet or avenue. The same is the case with the semen. Although,
therefore, the doctrine of the separate existence of hydatids seems to be
pretty generally adopted, we confess it is one to which we cannot recon-
cile ourselves. We have not room, however, to discuss this subject at
present.

In the next chapter, we come to the adventitious serous cysts. Our
author remarks that whatever may be the nature of hydatids, he thinks
he has given sufficient reason for their distinction from these cysts; the
former being found loose and unsupported, and the latter closely attached
and nourished by vessels proceeding from the part in which they are con-
tained.

'I’hese cysts are divided into two classes, those that form around an ex-
ternal body, and those that produce their own contents. The second class
form the subject of present consideration. Of these he wishes to distin-
guish and set aside, four species that have been classed with them as pro-

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dueing their own contents. 1. Hydatids; 2. subtegumentary encysted
tumours; 3. cysts formed by the parietes of an obstructed canal; 4. cysts
formed by the distention of natural cells; such as the enlarged vesicles of
De Graaf; 5. cysts formed in the thyroid gland, such as constitute bron-
chocele.

Having set off these, he divides the remainder into two classes, sim-
ple and compound. The first are found solitary, or if associated with one
or more similar to themselves, the connection is merely accidental. The
other class possess the remarkable property of giving rise to growths,
having the same character with themselves.

Serous cysts of the simple class are found in the plexus choroides, in
the eyelids, in the lungs, in the mamma, and in the neighbourhood of the
uterus.

Of the compound cysts, the largest and most interesting are those which
are found in the neighbourhood of the uterus, in or near the ovaries, and
in the folds of the broad ligament. The parietes of these cysts are found
studded with elevations or tumours, which, upon examination, are perceived
to contain within them other tumours of a similar kind, the membrane or
cyst of which covers the outer tumour, being reflected so as to form the
cyst of the one within it. Besides the contained cyst, there is found also
a quantity of serum or mucus in each sac. Cysts of the secondary order,
Dr. H. observes, not unfrequently afford as complete a specimen of re-
flected serous rnembrane, as the pericardium or tunica vaginalis. These
tumours are distinguished from hydatids, because the secondary cysts are
attached to and continuous with, the internal surface of those in which
they are contained; and because delicate vessels are seen ramifying from
the one to the other. The superior cysts sometimes become distend-
ed and ruptured by the formation and growth of an inferior order of
cysts, or by the accumulation of fluid, and discharge their contents
into the containing cyst; and thus allow of the nnrepressed growth
of those which they contain. The cysts thus opened, bear a conside-
rable resemblance to mucous follicles, and appear to be the principal
source of the copious and rapidly formed mucous secretion, characteristic
in many cases of ovarian dropsy. The effusion of plastic matter, when
the membranes of these cysts become inflamed, produces adhesions which
render it difficult to demonstrate their structure. There are two varieties,
which differ from those above described, the first consisting in the attach-
ment of the contained clusters by slender peduncles, and the second, by
broad and flat connections. The three forms may however exist in one
cyst, tliough there is generally a preponderance of one or the other.

A possible cause of these tumours. Dr. H. thinks, may arise from the
lesion attending the escape of vesicles, wdiich may occur in virgins as well
as others. This growth is more rapid, because the parts in which they
arise are accustomed to obey a stimulus to an increased supply of nou-
rishment: because these parts are abundantly supplied with blood; and
because the situation exempts them from all pressure ‘or restraint. Dr.
H. thinks that the only effectual cure is by their extirpation, to wdiich he
thinks there can be no absolute objection, if done sufficiently early.

The same form of tumours occurs in what has been called hydatid tes-
ticle, and hydatid breast. Sometimes it occurs in the eye. One of the
forms of staphyloma, which is not malignant, appears to be of this
nature.

Hodgkin’s Lectures on Morbid Anatomy.

143

In the ninth lecture, we have the consideration of the results of malig-
nant disease. Here we have: first, adventitious cysts accompanied with a
constitutional taint. Second, scirrhus. Third, fungoid disease. Fourth,
melanosis. Our author thinks that all these have general points of re-
semblance. He believes that the common method of examining such tu-
mours by making sections through their substance, especially after they
have been immersed in alcohol, is deceptive, and that the best preparations
do not supply the place of recent sj)ecimens.

By a carefully conducted dissection, we shall, according to him, arrive
at appearances similar to those described in the last chapter. He describes
the formation of these heterologue tumours as analogous to that of the ova-
rian cysts. In short, if we conceive of the various forms of cyst w hich
may be composed with a reflected membrane, such as the tunica vaginalis,
we have the composition of these tuntours. Within the larger cysts are
secondary cysts, in the same manner as in those before described. Pres-
sure, impeded nutrition, and deaths are occasioned in these as in the ova-
rian tumours, by strangulali«)n from the growth of the secondary cysts. The
eflect, however, is dilferent. 'The dead cyst, having become a foreign
body, excites inflammation in the parts with which it is in contact. 'Jdie
result of this, is the formation of a cavity filled with broken down and
softened matter, intermediate between suppuration and gangrene. 'This
often takes place befijre the tumour shows any external symptom of irrita-
tion or infiammation, but it requires that the supply of nutriment should be
pretty promptly cut ofl" by the natural ligature.

These tumours produce by their irritation a thickening of the surrounding
cellular membrane to a less or greater degree, and dilate the integuments so
as to become visible externally. 'J’he points most distended inflame, and
the inflammation proceeds to ulceration. 'I'lie tumour eitlier sprouts vigo-
rously in consequence of the removal of pressure, or what is more frequent,
participates in the ulceration. 'Phe ulcer formed has been considered
characteristic of malignant disease. It has elevated and everted edges with
a ragged and depressed central portion which is bathed by an unhealthy
secretion.

Its growth is most luxuriant at its circumference, botlt on account of the
want of pressure, and from the increased sup[)ly of nourishment. 'The
central parts have to encounter the pressure of the surrounding parts of the
tumour; and at the same time, all supply of nourishment from the natural
structures, is cut off by the ulceration of the integuments. The depth and
irregulariiy of the ulcer is increased bv a communication which is formed
with tiie cavity in the interior of the tumour. By making a section through
the diameter of t e ulcer in a recent specimen, proof will almost always be
found, that the elevated margin is composed of radiating pedunculated
bodies; whilst in the centre, this disposition is less distinci; tfie structure
is more condensed and there is little if any trace of organization.

With regard to the manner of distinguishing malignant tumours our
author concludes a discussion upon this subject as follows: “For my own
part, I should, in examining a tumour in the living subject, be in general dis-
posed to suspect what has been called malignity, whenever I could detect
indications of the structure which I have described, accompanied with al-
terations of the surrounding structures, referrible in their origin to some
external violence, or to a pre-existing indolent tumour. These suspicions
would be proportionally stronger, if the tumour in question occurred in a

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part known to be rarely if ever affected with that now malignant arfd well
defined form of tumour commonly termed ‘ hydatid,’ which in common
with those of a malignant character, distinctly possesses the structure al-
luded to. My suspicions would be converted into absolute certainty, in
proportion as the other symptoms previously detailed were united to those
which I have assumed, as presenting themselves in the suspected tumour.”

Dr. H. remarks that the structures of the body possessed of the best
vitality, such as naevi materni, the thymus gland, the suprarenal capsules,
the mammae are, most frequently, the seats of malignant disease. This
liability he considers to depend rather upon innervation than upon vas-
cularity.

The distinctions between scirrhous and fungoid tumours, form the sub-
ject of the next lecture. True scirrhous tumours sometimes appear to de-
pend upon a single primary tumour; at other times, several can be distinctly
traced. The part of the tumour which appears to have been the common
origin of the primary cysts, where there are more than one, or from
which the contained pedunculated bodies radiate, when there is only a
single primary tumour, is, in general, the most indurated portion, and at the
same time, the most indistinct in its structure. When examined after the
surrounding structures have been carefully dissected off, this part is found
irregular and corrugated, suggesting the idea of its having formed a sort
of root to the adventitious structures. True scirrhus may remain indo-
lent for a length of time. Before ulceration takes place, the tumour be-
comes adherent to the skin, and a small spot becomes of a bright or cherry
red, or a livid purple colour, before the skin is broken.

Dr. H. is of opinion that scirrhus never degenerates into fungus, al-
though they frequently exist in different parts of the body of the same
person. True scirrhus, he thinks, has sometimes been cured sponta-
neously, the tumours becoming detached by the sloughing of the surround-
ing tissue, and thus completely thrown off from the system. The occa-
sionally successful practice of empirics, whose principal agent appears to
be arsenic, consists, he thinks, in the attempt to induce this process artifi-
cially. He mentions a lady afflicted with cancer of the breast, who placed
herself under the care of a female quack; and by the use of secret means,
the tumour was detached entire. The wound was closed, leaving a very
trifling cicatrix, and the lady has had no return of the affection. Dr. Viale
at Rome, informed him that he had long been in the habit of adopting a
similar plan, in malignant and other tumours, with very considerable .
success.

Fungoid disease may, in general, be distinguished from scirrhus by its
more rapid progress, the prodigious size to which the tumours sometimes
arrive, and by its superior vascularity. Its greatest ravages occur in the
young; while true scirrhus is almost exclusively the disease of advanced
life. The fluid matter is very abundant in the former structure, while in
scirrhus it forms scarcely a notable part. The secondary cysts of fun-
goid tumours, which are often large, generally become filled with a mate-
rial at first resembling feebly coagulated fibrine or plastic lymph. New
vessels shoot into this substance which loses its vitality, gradually be-
comes opaque, and resembles the brain of a child.

The cellular structure around scirrhous tumours becomes frequently in-
flamed by the irritation they produce, and is thereby thickened and indu-
rated. The implication of the nervous fibrillae in this altered structure.

Hodgkin’s Lectures on Morbid Anatomy. 145

Dr. H. considers the cause of the peculiar and lancinating pains that attend
an access of inflammation to which the affected part is constantly liable.

The eleventh lecture, upon the subject of colour^, we must pass over,
and proceed to the twelfth, and last of this volume, which is occupied wdlh
those malignant tumours that have obtained separate attention in conse-
quence of their colour.

The first of these is cirrhosis, which he considers only a modification
of fungoid disease, and hardly requiring separate consideration. The
yellow colour is merely an accidental character attached to a particular
form of malignant disease, in a particular state of its existence.

Melanosis derives its black colour from a highly venous state of the
blood, induced by its prolonged stay in the vessels. It has always an en-
cysted form. When the tumours are situated in loose cellular membrane,
they have always a rounded shape; but when subjected to pressure, they
are modified by this cause. The two most obvious characteristics of
melanosis are the black colour, and the production of a new growth pos-
sessed more or less distinctly of the characters of the whole group of ad-
ventitious deposits that have been described. Dr. H. describes lastly a
species of firm fleshy tumour, distinguished by its peculiar structure, and
the obscurity of the encysted character, which nevertheless essentially
exists in it. The best specimen he had seen grew from the neighbour-
hood of the scapula. He regards them as of a fungoid nature. This
lecture concludes with a full discussion of the various theories which have
prevailed or have been put forth with regard to malignant tumours. The
appendix contains many cases in addition to those dispersed throughout the
lecture, illustrative of the doctrines and descriptions therein contained.

The whole of the volume is highly interesting, the style of our author
is elegant, and his descriptions are clear and lucid, and undoubtedly accu-
rate. Perhaps he may be a little disposed to theorise: an inclination with
which the less fault can be found, since his high standing as a morbid
anatomist, render even his theories valuable. The ditfuseness of the lec-
ture style, while it renders his descriptions, we think, more clear, and
certainly more pleasant, is unfavourable for quotations: from which we
have therefore been obliged to abstain, except in one or two instances.
One recommendation of the work we ought to mention, as it is an im-
portant one, in a book intended for general use. The author has purposely
abstained from the introduction of plates, in order to render it less expen-
sive; and therefore more accessible than the works of Carswell, Cruveil-
hier, and others. The second volume has not yet appeared, and we regret
to learn that the health of Dr. Hodgkin is such as to afford no present
probability of his prosecuting the work. E. W.

Article XIII. First Principles of Medicine. By Archibald Billing,
M. D., &c. &c. Third Edition, considerably Enlarged and Improved,
8vo. pp. 282. London: 1838.

Dr. Billing deserves the thanks of the profession for his attempt, in the
volume before us, to reduce into a small compass, and at the same time to
simplify as much as possible, the principles of general pathology and
therapeutics. His doctrines of the nature and treatment of diseases are
No. XLVIl — May, 1839. 13

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professedly the result of an extensive clinical experience, and based upon
the well established physiological laws of the animal organism.

However we may be inclined to deny the accuracy of some of the doc-
tor’s positions, and the legitimacy of many of his deductions, we cannot
but concede to his views, in general, the praise of great ingenuity and
plausibility, while, in many respects, we admit, that they present a much
more rational explanation of the phenomena of disease and of the curative
effects of remedies, than the leading hypotheses of the day.

Although small in size, the work of Dr. Billing contains so large an
amount of novel ideas, concisely expressed, though not always very logi-
cally arranged — while his physiological, pathological, and therapeutical
expositions are so intimately blended, the one constituting the proof or
illustration of the other — that it is somewhat difficult to present a satisfac-
tory analysis of its contents.

To understand distinctly the author’s views of inflammation, fever, and
the neuroses, to which three classes he would appear to refer all the usual
groups of morbid phenomena, it will be necessary to premise some few of
the leading physiological positions advanced by him.

The nerves, he maintains, are distributed to every part of the frame,
however minute, for the purpose of supplying to them nervous influence,
which excites action. He supposes the muscles and capillary arteries,
though differing in tissue, to have each inherent in their structures, a
faculty of contracting {orp^anic contractility)^ which being acted upon by
the nervous influence, the result is contraction: the nervous influence being
discharged into them from the nerves. This discharge may be produced
in a variety of ways: as by the blood in the heart or capillaries, the pre-
sence of food in the intestines, or, in the muscles, by the will, whether
the operation be direct or by rejiection^ these being known agents of con-
traction in the animal.

“ We have reason to believe that the nervous influence is generated, or
secreted, in the cineritious (gray) part of the nervous system, and con-
ducted by the medullary (white) part; the medullary part in the spinal cord
and brain being an aggregation of nerves from the frame. And a variety
of circumstances lead us to the conclusion, that the nervous influence is
analogous to, or depending upon, if not identical with, the electric princi-
ple or fluid, whatever that be.”

While we may admit the first of tliese suggestions, the second position,
namely, the dependence of the nervous influence upon the electric princi-
ple, is disproved by so many facts, that with Miiller, we must entirely
deny its accuracy.

All organic action the author asserts to be contractions produced by
nervous influence. He, therefore, denominates the susceptibility of any
tissue to contract, organic contractility; its contraction, organic action —
sensibility being considered by him solely a property of the nerves.

The energy of parts depends, according to Dr. B., upon a something
that is communicated to them by the nerves in conjunction with the brain
and spinal marrow; while they are supplied with this nervous influence
they retain their power of action, and no longer. Thus arteries become
insusceptible of impressions from external agents when the nervous ener-
gies are low; and when the vital powers are sunk the capillaries cease to
secrete. Nervous influence is elicited in producing nervous actions^ such
as peiceptions or thought; organic actions, such as of the capillaries,

Billing’s First Principles of Medicine • 147

lieart, or intestines; and the combination of nervous and organic actions —
voluntary motion.

“ If this expenditure exceed the supply, or secretion, by the cineritious
part of the nervous system, exhaustion is evinced in various ways: in
health by sleep; in disease by delirium, stupor, or death.”

“ Sleep is a cessation of that expenditure of nervous influence which
takes place in nervous action; such as volition, and other functions of the
sensorium, organic action continuing. The expenditure of nervous in-
fluence going on under ordinary circumstances, quicker than the generation
of it, a periodical return of sleep is induced.”

Animal heat is, agreeably to the views of our author, extricated, all over
the frame, in the capillaries, by the action of the nerves during the change
of the blood from scarlet, arterial, to purple, venous; and also wliilst it is
changing in the lungs from purple to scarlet.

“ There is,” he remarks, “ a perpetual deposition, by the capillary sys-
tem, of new matter, and decomposition of the old, all over the frame, in-
fluenced by the nerves; in other words, the galvanic influence of the
nerves, which occasions these depositions and decompositions, keeps up a
slow combustion. In this decomposition there is a continual disengage-
ment of carbon, which mixes with the blood returning to the heart at the
time it changes from scarlet to purple; this decomposition being effected
by the electric agency of the nerves, produces constant extrication of
caloric; again in the lungs, that carbon is thrown off and united with
oxygen, during which caloric is again set free; so that we have in the
lungs a charcoal fire constantly burning, and in the other parts a wood fire^
the one producing carbonic acid gas, the other carbon — the food supply-
ing, through the circulation, the vegetable or animal fuel from which tire
charcoal is prepared that is burned in the lungs.

“ It is thus that the animal heat is kept up. On the other hand, the
evaporation of perspiration keeps the surface cool; but in inflammatory
fevers, where this is deficient, the body gels loo hot; and in low fevers,
where the nervous influence is not sufficient to keep up the full fire, the
surface gets cooler than the natural standard.”

With this brief notice of some of the leading physiological views ad-
vanced by our author, we shall be prepared to understand his pathology of
inflammation and fever.

He very properly remarks that every disease is some alteration of those
actions, v/hich, when perfect, constitute the welfare of the animal. In
inflammation, the first action of the morbific cause is upon the nerves ap-
propriated to the capillaries, diminishing their energy, and consequently
the contraction or organic action of the latter; in consequence of which
the capillaries dilate, and receive a larger amount of blood than in their
healthy state, which is also transmitted more slowly to the returning ves-
sels or veins. The action of the capillary arteries in an inflamed part is
hence weaker than in parts of similar texture unaffected with inflamma-
tion— which is proved by the redness and swelling of the inflamed part.
The enlargement of the vessels observed in a tissue labouring under in-
flammation, and the consequent increased redness and intumescence of the
tissue being the result of diminished contraction, or* action, of the vessels,
allowing them to give way and become dilated by the injective force of
the heart.

The difference between congestion and inflammation is, according to
Dr. B., that in the former there is simple distension of vessels; in inflani-

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mation there is more or less alteration of tissue, connected generally with
deposition in some way of coagulable lymph.

“ The moment congestion is relieved, the parts are in their natural
state; but even after inflamed vessels are unloaded, time is required for
recovering their natural slate. A good example is the congestion of the
lungs in fever, which often leaves no symptom when the fever is relieved;
but after inflammation of the lungs has been stopped, the injured vessels
require time for restoration.”

'i'his exposition of the author appears to us to besufficient to show that,
contrary to his opinion, inflammation consists in something more than over
distension of the capillaries of a part consequent upon their enfeebled action.

“ The progress of inflammation shows the dependence,” remarks Dr. B.
“ of the capillaries on the nerves. A part may, in certain cases, be observed
to become tender before it is red; for it may be seen by experiment that
the pleura or peritoneum of an animal is not tender immediately on ex-
posure; it first becomes tender and then red. In inflammation of the con-
junctiva of the eye, it becomes painful, feeling as if there were sand under
the lid, some time before becoming red. 'rhe action of cantharides in
producing inflammation is another proof that inflammation begins in the
nerve: for cantharides have no effect on the tissue of the capillaries, do
not corrode or act in any way on their substance after death, when the
nerves have no influence; whereas any really corrosive agent would act
even more on the dead than on the living capillaries. Without, therefore,
at present seeking for further proofs, I deduce from blushing, and from the
effects of electricity, fire and cantharides, that the capillaries depend upon
the nervous system for that tone or energy which preserves them from
over-distension. The brain, spinal cord, and nerves, again depend upon
the due nutrition by the arteries supplying them with scarlet blood.”

Dr. B. very properly objects to the terms in common use, of blood being
detained in a part by local irritation; the blood being merely delayed in
the inflamed tissue in consequence of the increased capacity of the vessel
causing a slower current there; and of the determination of the blood to
a particular part — the heart, he remarks, has no power to direct any blood
to one part more than another, but, if in any part there be an unusual
relaxation of the vessels, they will receive more than ordinary.

“ As long as the capillaries are supplied with nervous influence, as long
as they possess perfect organic action, they preserve a due size; when they
lose it, either from the influence not being supplied from the nervous sys-
tem, or are robbed of it by heat, electricity, cantharides, or other cause,
they give way, and admit more blood than before. Taking this view of
the proximate cause of the enlargement of the capillaries, we can account
for all the varieties of congestion, from a single transient blush to the stage
with which inflammation commences; and it must be impossible to draw
a line between congestion and inflammation, one passing into the other by
insensible shades. Hence the numerous terms used by authors to express
the gradations of distended capillaries; congestion, active and passive, en-
gorgement, hyperagmia, erythema passing to erysipelas, &c.”

According to Dr. B. the effect of inflammation, as is evident from its
proximate cause, (relaxation of capillaries,) is to soften the tissue in which
it takes place. An inflamed part may feel hard on account of tension, but
when cut into, the inflamed tissue will be found softened.

The diminished secretion consequent upon inflammation, the author ex-
plains by the enlarged capillaries allowing a more free passage to the blood

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onwards into the veins, than through the pores in the sides of the vessels
into the ramifications of the excretory tubes; the capillaries at the same
time being unfitted for secretion, in consequence of the morbid alteration
of their physical condition, and yet, more particularly, tlirough the altera-
tion of their dynamic (galvanic or electrical) condition, consequent upon
the alteration of the supply of nervous energy to the part, the original
cause of all disturbance.

“ In some cases of disease, when the secretions of the skin and kid-
neys are deficient, we renew them by bleeding, digitalis, antimony, &c.,
which lower the force of the pulse, thereby diminishing the distension of
the capillaries. On the other hand, in health, stimulants, such as punch,
by increasing the nervous energy in the kidneys, &c., and quickening the
circulation, at the same time increases secretion — whereas the same stim-
ulus could not increase secretion by quickening the circulation when the
capillaries are in a state of debility and morbid congestion — and a still fur-
ther proof that they are in a state of morbid enlargement, is the efifect of
cold applied to the loins in such cases, in renewing the secretion, and the
effect of cold water, even cool air, in promoting the secretion of insensi-
ble perspiration, and thereby softening the skin, in scarlatina. Increased
secretion takes place sometimes with a weak pulse. It will be found that
this occurs in cases where, although the circulation is weak, the capilla-
ries are not deficient in nervous energy, as in hysteria, in the sweating of
hectic, &c.”

In the mucous membrane lining the different canals, the effects pro-
duced by a minor degree of inflammation is, by the relaxation of the ex-
halent capillaries, to produce a more rapid extrication of the fluid part
of the blood; hence the saline serous fluid poured out in the slighter forms
of catarrh or the increased flow of a mucous or serous fluid in diar-
rhosas. If the inflammation increases, the mucous surfaces become dry
from a diminution or suspension of their secretions — but as the inflamma-
tion subsides, the vessels recontracting, secrete again a mild scanty mucus.

The proposition, that “ inflammation is the means by which local in-
juries are repaired, and hence may be considered as the restorative prin-
ciple,” Dr. B. denies in toto. He contends that it is invariably a mor-
bid condition — that the term adhesive inflammation is an entire misno-
mer, inflammation invariably impeding the adhesion of cut surfaces or the
granulation and cicatrization of an ulcerated surface.

Morbid sensibility of a part does not, according to the author, occur
during the reparatory process. There may, he admits, be a considerable
degree of pain in those cases in which the healthy nerves are exposed
and injured. But there will be more disturbance and loss of sleep, with
perhaps less pain, if, from the nerves themselves becoming inflamed, (he
has no other term to express their lesion,) morbid sensibility arises, either
locally, or in the nervous centres, in consequence of the lesion of the
nerve being communicated to them, whether the lesion be in the sensi-
tive or organic filaments; in the latter case, there can be no evidence of
morbid sensibility until the lesion is propagated to the nervous centre.

The term inflammation, Di. B. restricts exclusively to the phenomena
which exist previously to the deposition or effusion of coagulated lymph
or the natural process by which the reparation of the injury inflicted on
the part by the inflammation is effected.

“ I may be asked,” the author remarks, “ how it happens, if the

13*

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throwing out of lymph be not a part of inflammation, that it occurs as
one of the phenomena of erysipelas, and also upon inflammation of the
cornea or iris, when instead of deserving to be named a part of the re-
paratory process, it obstructs their functions. In erysipelas sufliciently
severe to cause lymph to be effused, the desquamation is evidence of so-
lution of continuity of the capillaries, hence the necessity for the repa-
ratory process, viz. the effusion of lymph. We may fairly deduce, by
analogy, that there is likewise solution of continuity of the capillaries in
the cellular substance beneath. The moment this solution of continuity
of capillaries — the giving way from the degree of inflammation, takes
place, lymph is effused, and its use is evident, viz. to reunite the breach
as even in cases of reparation of an incised wound. When the cornea is
wounded, we see that the effusion takes place, to reunite the capillaries;
in like manner, when the capillaries give way from inflammation of its
substance, without breach of surface, lymph is eflused for the reparation
of damage. Had the inflammation been superficial, the giving way of the
capillaries would have been evinced by ulceration.”

Upon this distinction between the inflammation and reparatory process,
Dr. B. explains the important practical precepts; the impropriety, namely,
of continuing to bleed and to employ other antiphlogistic remedies after
the first has entirely subsided — and the importance to be derived from
opiates administered at this stage to subdue the morbid sensibility which
often remains after the inflammation, and to support the system during
the restorative- process under a great injury.

“ This use of opium,” he remarks, “ has been pointed out empirically
by the best authorities, as they say, in peritonitis and pleuritis — but it is
evident that it is after peritonitis (the inflammation,) or whilst it is subsid-
ing, and during the reparatory process — and on any relapse of the inflam-
mation evinced by the skin becoming hot and dry, the opium must be
combined with renewed antiphlogistic remedies. In the cases alluded
to, the opium is given immediately after free bleeding; the bleeding
checks the inflammation, and the opium removes the morbid sensibility.
The case must be closely watched for febrile symptoms, lest the ano-
dyne by allaying pain, deceive the practitioner (of which there is great
danger in inexperienced hands), and the inflammation re-light, as it will
unless antiphlogistic medicines, such as antimony, digitalis, neutral salts,
&c., be administered to keep it in check, in graduated doses, but by no
means freely, though that was necessary at first.

“ On the other hand, in many protracted cases of disease, when the
patient feels scarcely ill enough to apply for medical advice, we find some
latent inflammation, requiring active and decided antiphlogistic treatment,
which may surprise the patient, but of which he soon feels the benefit.”

When the congestion or inflammation existing in a part subsides without
solution of continuity, or leaving any trace behind, it is called resolution.

The following extracts will explain the author’s views in relation to the
formation of ulcers, abscesses, and the phenomena connected with them.

“ If by a blow or other injury, as by caustic, or by any inflammation,
the life of a portion he destroyed, it gradually decomposes, and sepa-
rates from the living part — sometimes in the form of a discoloured slough,
the fluid parts running off when the slough is on the surface. The
separation is effected by decomposition, and not by the absorbents of the
living part removing a portion of the dead parts, as has been asserted:
the part at the line of separation, of a slough of the skin, for instance, de-

Billing’s First Principles of Medicine, 151

composes most rapidly, from the heat and moisture of the surrounding
living part; whereas the centre of the slough often dries up, like a piece
of leather. After the separation of a slough on the surface of the body,
an open wound is left, .which, if the reparatory process go on naturally,
will be filled up by granulation.’’

“ Ulceration is the death of successive layers or minute portions of an
open wound, of whatever dimensions; the solution of continuity having
been affected either by spontaneous inflammation and decomposition, or
by external injury — and the matter which successively dies in an ulcer is
not separated from the living part, nor taken away by the absorbents, as
has been generally asserted, but decomposes and runs off. Again, an ulcer
is not necessarily in a state of inflammation; for, on the contrary, whilst
healing, it is in a state of reparation; and any renewal of inflammation
causes enlargement — fresh ulceration.”

“ When any injury, from a blow or inflammation is sufficient to cause
death of a portion deeper seated below the skin, it is possible that the de-
composed matter may be carried off by the absorbents, as we see in the
case of an ecchymosis of extravasated blood — but in general, the repara-
tory process causing the secretion of pus, suppuration (an abscess)^ takes
place. Here again I must advert to the incorrectness of language ordi-
narily used: it is said that, when inflammation exists, it is of consequence
to prevent suppuration. Now, what is to be prevented is, the death of >
any portion — if that take place, the suppuration is merely a matter of
course, as a part of the reparatory process.”

The cavity of the abscess is. Dr. B. remarks, lined with coagulablc
lymph, analogous to the granulations and false membranes and adhesions,
in other cases of inflammation. The cyst of the abscess thus lined is
merely the cellular tissue of the part stretched upon the contained pus, and
does not, according to the author, set bounds to the abscess, but passively
depends upon the quantity effused into it. It is the extent of the inflam-
mation which decides the extent of the abscess; and where the inflamma-
tion is diffused or ramifies, we have diffused or ramified abscess, as
from diffused cellular inflammation.

The foregoing remarks refer chiefly to what is called acute inflamma-
tion, in which either resolution or destruction of parts takes place. Chro~
nic inflammation, according to the pathological views of the author, is that
in which the cause of the inflammation remains, producing reiterated le-
sion, followed by continual efforts of the reparatory process, in depositing
coagulated lymph, which —

“ Sometimes becomes organized and produces actual hardness, as in
strumous and other tumours, syphilitic nodes and warts, chronic hepatitis,
&c. Sometimes a persisting open ulcer, as a chancre, in which the repa-
ratory process goes on, and by depositing lymph thickens the edges,
whilst the continued inflammation keeps the ulcer open by the successive
death of minute portions; or, if it be not strong enough to produce death
of portions, so as to keep the part in a state of open ulcer, it still renews
enough of inflammation to prevent healing — that is, the organization of the
cicatrix, which therefore becomes a scab; sometimes single, constituting a
scale, as in the coppery eruption; sometimes in successive layers, as in
rupia; sometimes in clusters after pustules, as on the face. It is thus that
a morbid poison not only inflicts the injury, but, by adhering in the tissue
or constitution, perpetuates it till expelled by some remedy.”

Dr. B. very properly remarks, that no essential difference exists between

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phlegmonous and erysipelatous inflammation— it being the same inflamma-
tion in both cases — the only difference being in degree or situation, and
dependent upon the state of the constitution. If there be no death of
part, there will be no slough; no necessity for the suppuration; but merely
desquamation of cuticle or even resolution. The stages, from a slight
erysipelatous blush to the most violent inflammation and sudden mortifi-
cation, are not differences but degrees — exactly analogous to the action of
fire, from a slight scorch to the actual cauterizing which causes the death
of the part instantly. The two things which produce the source of the
phenomena, are, according to the author, the injury and the constitution —
great injury with little debility of constitution inducing the same result as
less injury with greater debility.

The remarks of the author on the pathological peculiarities of the infec-
tious, contagious, and what have been termed constitutional diseases, are
ingenious, though not altogether original.

Tumours, according to Dr. B., are the result of accidental injuries, as
blows, &c., or of disease. In both cases coagulable lymph is effused in
the cellular tissue, and by a process analogous to granulation, becoming
vascular and organized, cannot be removed by the absorbents, which only
take up unorganized or dead matter. Some of these tumours remain un-
altered, others by their presence keep up an inflammation, in consequence
of wliich the capillaries go on depositing more and more by necessarily
reiterated reparatory effects, and so add to the tumour which is thereby
increased in size, until it is removed by remedies or operation or exhausts
the animal and destroys life. Tumours sometimes disappear spontaneously,
that is, by a cessation of the inflammation which produced them, and their
subsequent re-absorption — sometimes they suppurate, forming abscesses;
sometimes remain indolent; at others, remain and grow larger, or grow larger
and ulcerate at the same time, as in cancerous and other malignant diseases.

“ Tumours are modified by the part they occupy and the constitution
of the person — if the substance injured be fat, the arteries there being de-
positors of fat, make a fatty tumour — if it be periosteum, bony — if a
highly vascular part, a vascular tumour., 'i'he tough bands which tra-
verse fatty and other tumours are made by arteries, which in a healthy
state would have to support membranous, cellular, or ligamentous tissues.
A tumour of a lymphatic gland, or other part, in that debilitated, relaxed
consiitution called strumous, or scrofulous, will become so: and in a
constitution tainted by cancerous disease, cancerous tumours will form in
any and every part, as has been ably demonstrated by Kiernan. The
same may be said of tubercular disease, which is totally distinct from
common inflammation.

“ If the absorbents cannot take up matter which is organized, it may
be asked how they get away tumours? The organization of a tumour is
but imperfect, and it is a burden on the previously existing arteries, in ad-
dition to their originally allotted task: if these arteries have been enlarged
in size (for we know arteries can grow larger,) in consequence of the in-
flammation which gave rise to the tumour, they will go on to support it,
but if they have only been dilated, they will, when the inflammation sub-
sides, resume their natural size, and starve the tumour, the constituents
of which will, when thus deprived of support, become decomposed, un-
organized, and thus amenable to the absorbents: on the other hand, the
tumour may have been too well organized to give way, and so continue
an indolent life, after all inflammation has subsided,' but producing neither

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Billing’s First Principles of Medicine,

pain nor inconvenience, unless a blow or other cause renew inflam-
mation. Now, if the efforts of nature do not remove the tumour, we
have remedial means of diminishing it.”

These means consist of such as prevent nourishment from entering its
vessels, or diminish the amount of blood in them, or cause them to con-
tract, and wliich cause the removal of the morbid growth by starving it.

From the foregoing the reader will be enabled to form a tolerably accu-
rate idea of the leading outlines of Dr. B’s views in regard to the patho-
logy of inflammation. In strict conformity with those views, he attempts
to explain the modus operandi of the various remedies which experience
has proved to be the most successful for the removal of inflammation.

He maintains that the only way in which inflammation of a part can be
diminished, is by increasing the action of the arteries involved 'in the dis-
ease, by cold or astringents, which cause the arteries to contract; that is,
increase their action.

“ When the eye, or any other part, is injured by heat, or a stream of
cold air, a blow, or cantharides plaster applied to the skin, &c., the part
becomes redder from the vessels enlarging and admitting a greater propor-
tion of blood than there was before. Now, in this first and simplest in-
stance of inflammation, the heart does not act more strongly than ordinary,
not affecting the pulse, so that the capillary arteries evince debility, having
given way when there is no more force than they bore before without dis-
tension; from this they sometimes recover of themselves, gradually con-
tracting to their natural size; or if not, the simple application of cold, or
an astringent lotion, makes them contract, and the redness disappears.”

“ The more the heart acts the more of course it forces the arteries of
the inflamed part; and the pulse, showing the power of action of the heart,
is erroneously by some considered as an evidence of arterial action; the
throbbing of the carotid arteries for instance. As the heart, therefore, acts
against the capillaries, if we cannot cause them to contract strongly enough
to resist its force, we are obliged to diminish the force of the circulation,
either by taking away blood, which decreases both the quantity of blood
sent to the arteries and the action of the heart itself; and in this way we
leave less for the arteries of the inflamed part to do; or we can lower
the force of the heart by medicines, such as digitalis, &c. Here, for illus-
tration, the simplest cases of inflammation have been taken, in which the
heart is acting naturally, the inflammation being from injury.”

When the minute arteries have suffered so much that they cannot re-
cover of themselves, nor by the aid of mere local application, in addition
to the local disease symptoms of constitutional disturbance arise, as rest-
lessness, or a general sense of uneasiness,* and increased action of the
heart; showing that the nervous system is partaking of the morbid sensi-
bility of the nerves of the inflamed part, and that the heart is becoming
more excited by its ordinary stimulus, from its nerves being more suscep-
tible. The increased force in the injecting action of the heart tending to
keep up and aggravate the disease, it is necessary to diminish its action,
and guard against removal. This may be done by venesection or by
leeches; by means of which we lower the pulse at the same time that we
relieve local fulness. All those things are now to be avoided that will
have a tendency to raise it again, as exercise and generous diet. In addition,
to low diet and rest, we may assist in lowering the pulse by sedatives and
by emetics and purgatives.

A variety of remedies, such as nitrate of silver, tartar emetic, acetate of

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lead, corrosive sublimate, &;c., and some acrid vegetables, as mezereon,
&c., that have been found successful in certain cases of inflammation,
either applied externally or administered internally, are, according to Dr.
B., to be viewed as astringents in their action upon the capillaries; each of
them, nevertheless, when too strong or used in too large doses, produces
a contrary effect, viz. inflammation and relaxation. Whether externally
applied or taken internally, the foregoing remedies are, it is maintained,
absorbed anil carried into the circulation, and in this way applied directly
to the capillaries of the inflamed parts.

“ We know, too,” he adds, “they are adapted to different cases. An-
timony, which produces sickness and lowers the pulse, besides its local
effect on the capillaries, when it reaches them through the circulation, is
suited to, and resorted to in, acute diseases, such as inflammatory fevers,
whether idiopathic or from injuries. If administered so as not to produce
sickness or nausea, or if there is a low state of fever, not requiring re-
duction of the pulse, the antimony may be given in small repeated doses,
so as to circulate to the capillaries, without depressing the system. Mer-
cury, which has not this nauseating property, acts less on the pulse than
antimony, but perhaps even more upon the capillaries, when circulated to
them; hence it is oftener used in chronic cases, both syphilitic and others,
besides being much employed in acute inflammation, pleurisy, peripneu-
monia, peritonitis, &c.”

To the objection, that the inflammation of the gums and fauces, pro-
duced by mercury, is a contradiction of the above explanation of its action
upon the capillaries, the author very ingeniously replies. —

“ Mercury stops inflammation by the same means in one case'as \i pro-
duces it in another — it contracts the capillaries; so that a healthy part is
inflamed and even ulcerated by what contracts its nutrient capillaries /rom
a natiiral state; an unhealthy ulcer is stopped by what contracts its re-
laxed capillaries to a natural state. Contraction of the vessels, however,
does not express the immediate cause of the sponginess of the gums;
there is, in fact, inflammation, relaxation, which is the secondary result of
the contraction; the excessive contraction occasioning the loss of contrac-
tility, that is, over-actions causing, at last, a loss of power: as cold, which
at first contracts, will at last destroy the power of the capillaries, so that
relaxation, amounting to inflammation (chilblain) takes place. The sore-
ness of the mouth in ptyalism is analogous to chilblain; the cold air,
saliva, &c., acting upon a membrane whose vessels are in a state of extra
contractility; moderate cold, with extra contractility, producing the effect
of intense cold with ordinary contractility. It is thus that w'e have, in the
rationale of medical phenomena, to refer constantly to the variation of the
proportions of the components of a sum; i. e. the two things which con-
tribute to a phenomenon. In the foregoing statement, the extra contracti-
lity depends upon extra sensibility of the nervous part of the apparatus —
the organic sensibility of Bichat — which is diminished, if not lost, when
inflammation takes place, and the augmentation of which is a means of
remedying inflammation, as a cold lotion may relieve a chilblain, which is
inflammation produced by cold, and as cool air relieves ptyalism.”

The purgative and emetic remedies so frequently resorted to in the treat-
ment of inflammatory diseases, such as salts, senna, jalap, tartar emetic,
calomel, ipecacuanha, &c., are, according to our author, sedative in their
operation. As a general sedative remedy, tartar emetic, so far from acting
as an emetic, will allay sickness, we are told; for example, inflammation

155

Billing’s First Prmciples of Medicine.

of the mucous membrane of the intestines is accompanied with nausea
and sickness, and inflammation of the lungs produces cough: both these
inflammations may be checked, even without bleeding, sometimes by fre-
quently repeated small doses of tartar emetic, which are by some called fe-
brifuge; and thus Dr. B. remarks “ tartar emetic stops vomiting or cough.”

“ Blisters act upon the same principle as heat, electricity, sinapisms,
capsicum, croton oil, acupuncture, &c. They all appear to produce an
increased influx of nervous influence to the part, whereby the capillaries
in the neighbourhood acquire an additional power of contracting, so as to
resist inflammation and inflammatory effusion.”

To understand the varieties of inflammation, we are to recollect, accord-
ing to our author, that the heart is acting against the arteries, and that both
heart and arteries derive their power from the nerves. Thus, inflamma-
tion, with a very weak pulse, the heart acting even more feebly than natu-
ral, as we see in broken down constitutions, where the capillaries being
even weaker in proportion, give way, and the inflammation is to be cured
by stimulants which raise the pulse, but which, at the same time, by im-
proving the appetite and digestion, nourish and increase the energy of the
nervous system, so as to enable it to communicate to the capillaries a tone
or power to resume their healthy action, more than equivalent to the in-
creased action of the heart.

“ In some cases, by good food and tonics^ such as bark, without stimu-
lants, we communicate an energy to the nervous system, which restores
the healthy action of the capillary arteries; and it is the discrimination of
cases where stimulants are admissible with tonics, or where tonics
should be accompanied by evacnants, that constitutes skill in conduct-
ing the constitutional treatment of many diseases. Thus by a refer-
ence to the relative state of action of the heart and arteries, bearing in
mind their dependence upon the nervous system, we can understand how
tonics are useful in many instances, by communicating power to the ca-
pillary arteries, through the nerves, where stimulants would be injurious
from their increasing the heart’s action. Tonics are likewise beneficial in
conjunction with abstraction of blood and evacuant remedies, in keeping
up the energy of the nervous system, so as to restore the proper action of
the capillaries.”

It is our object to present to our readers a very general outline merely
of the leading pathological and therapeutical views of Dr. B. To enter
into details connected with them, or to attempt a critical examination of
them, would extend the present article to an unreasonable length. Many
of the subjects touched upon in the work before us, which is more replete
with important matter than many a volume of more imposing dimensions,
we are obliged to pass over without notice; among these are the very in-
genious and interesting remarks of the author on that morbid state of the
nerves, whether partial or general, to which the term “ irritation” has
been usually applied, but for which he has adopted the appellation, morbid
sensibility; and by which he explains the occurrence of morbid sympa-
thies; as well as his practical observations on the four classes, stimulants,
sedatives, narcotics and tonics, into which he has arranged all the ordinary
remedial agents. In his remarks on each of these classes of remedies
will be found, combined with not a little plausible hypothesis, many use-
ful hints, calculated, w'e conceive, to lead to a more rational and successful
application of them for the removal of the several diseased conditions of
the system, than the usually received therapeutical precepts.

156

Reviews,

We shall proceed now to present a brief sketch of the author’s views
in rejrard to that much disputed subject, the pathology of fever.

When a local inflammation, in whatever organ seated, is either too great
to yield to the remedies applied, or when it has been neglected, it keeps
''up and extends the morbid sensibility of the nervous system; so that in
addition to the increase of pulse, we have other evidences of disturbance
in the functions of tlie nervous system, such as pains of the head, back,
and limbs, with lassitude or sense of debility, shewing that the nerves of
sensation and voluntary action are affected; alteration of temper; hurry of
thought, not amounting to delirium, but sufficient to indicate disturbance
of the functions of the brain; loss of sleep; false perceptions; chilliness;
morbidly increased heat of the surface with dryness, shewing want of tone
from deficient nervous energy. The digestive system is now also de-
ranged, the sympathetic nerves partaking of the morbid sensibility, as well
as the cerebral and spinal nerves, and of course the organs supplied by
them; there is loss of appetite, and imperfect secretions in the primae vise,
causing thirst, frequent nausea, and deranged function of the intestines —
constipation or diarrhma. The kidneys also evince a loss of power; their
secretion becomes dark, reddish, and scanty.

The combination of symptoms above enumerated, constitutes what the
author terms the constitutional disturbance, or sympathetic fever, from
local inflammation. This symptomatic inflammatory fever might, he con-
ceives, be called symptomatic synocha.

“It is the same assemblage of symptoms,” he remarks, “which forms
Cullen’s definition of the idiopathic disease, synocha, viz: heat much in-
creased, pulse frequent and hard, urine red, the sensorial functions but little
disturbed, and the power of voluntary motion diminished. The idiopathic
synocha sets in, in Cullen’s words, without primary (or preceding) local
disease; that is to say, the -symptoms of lesion of the nervous system are not
preceded by any hurt, or local inflammation, or pain, external or internal;
but the lesion of the nervous system in idiopathic fever is, in fact, the local
disease. It is, in my opinion, the nervous system itself, which, being in-
jured, produces synocha, or idiopathic inflammatory fever.”

The treatment in both the idiopathic and symptomatic synocha is. Dr.
B. remarks, the same; bleeding general and local, low diet and rest; atten-
tion to the bowels; sedative antimonial, or other emetic or diaphoretic
medicines; and the use of local applications, poultices, lotions, fomenta-
tion blisters, &c. Even in idiopathic synocha, local applications will be
beneficial as cold lotions, with leeches and blisters, &c., to the head, to
relieve the inflamed brain or meninges. Sponging the skin with water,
either warm or cold, also produces, the author observes, a sedative impres-
sion on a large proportion of the nervous system.

The foregoing state of fever having existed for some time, according to
Dr. B., the power of the nervous system becomes exhausted by morbid
sensibility, want of nutrition, &c.; and the heart, though still under the
influence of sympathetic morbid sensibility, deriving.less energy from the
enfeebled nervous system, and at the same time being less nourished, has
less power to contract, and really becomes weaker; and the pulse, though
still hard, is rendered weaker “also. From the same causes, the brain
sometimes from passing into inflammation, or at least congestion, has its
functions more impaired, and the thoughts become more confused, until
actual stupor, or delirium succeeds, and the pulse, losing its hardness, be-
comes soft and weak.

157

Billing’s First Principles of Medicine.

“ The heart being now unable to empty itself, congestion in the lungs
is produced, augmented by their capillaries being also deficient in power;
the blood, therefore, not being purified, causes still greater stupor, and the
patient is said to be in a state of typhoid (stupid) or low fever; instances
of which may be seen in local inflammation from disease or injury, as when
there is inflammation in the chest or abdomen, or after wounds or opera-
tions, where the sympathetic fever becomes typhous (typhoid). But if
the brain does not become inflamed or congested, the patient may die from
mere exhaustion, with all the senses perfect, as in hectic fever. Or we may
see a patient with symptomatic fever, typhous (typhoid), without having
had any previous strength of pulse, and with a cool skin, as from local in-
jury; when, for instance, with the injury, the nervous system has received
a shock, as in the case of a severe accident, or of an operation. Thus, we
may trace the progress from smaller injuries, and their consequences to
greater: a slight inflammation with morbid sensibility, as a single inflamed
haemorrhoid, produces shivering and heat of the skmffeverishness, pyrexia;
the spreading of this inflammation to a greater portion of the intestine pro-
ducing symptomatic inflammatory /ever; and a still further extension of the
mischief, general inflammation of the bowels, will bring on typhous fever,
with oppression of the sensorium. Now, by a similar series of events,
the synocha, or idiopathic inflammatory fever, may also become typhous,
which is Cullen’s synochus, a fever ‘beginning with synocha, and ending
with typhus.’ ”

Idiopathic typhus without any previous synocha, and with the tempera-
ture from the beginning, even below the natural standard, occurs, accord-
ing to our author, when the brain and nervous system are poisoned by con-
tagion, or by concentrated foul human effluvia, as in gaols, transport or
slave ships, &c., either with or without predisposing circumstances of
over fatigue of body or mind.

Dr.B. proposes the query, whether typhus and typhous fever consists in an
inflammation of the substance, and synocha of the investing membranes of
the nervous system, analogous to the difference between inflammation of
the substance and membranes of the lungs, liver, bowels, &c. Inflamma-
tion of the substance more completely interrupting the functions of an organ,
that of the membranes producing disturbance of action and pain. In
typhus, he remarks, we see, the functions of the nervous system, thought,
volition, sensation, &c., especially interrupted.

As in the treatment of synocha, so in that of typhus fever, attention, we
are told, must be paid to the local disease. In idiopathic typhus, especially,
lotions to the head to constringe and give tone to the vessels of the brain,
and leeches to relieve the congestion, are the essential local applications,
and the most unequivocal remedies in our power. Besides local applica-
tions, due attention must be paid to the alvine and renal secretions; but the
most important question is, the author remarks, as to the administration of
stimulants, or sedatives and depletives; and it is only by careful observa-
tion of actual disease at the bedside that we can arrive at the knowledge
necessary to guide us in this respect.

“ Experience, says Dr. B., proves that cold to the head, with moderate
saline and other sedative medicine, will cure typhus, or prevent the typhous
state from occurring in synocha; whereas when wine, with or without
opiates, is employed, the disease frequently proves fatal.”

“We may understand the risk of stimulating a typhous patient by sup-
No. XLVIL— May, 1839. 14 .

158

Reviews,

posing, that when an important organ, such as the lungs or brain, is in-
flamed, or even congested, the weak pulse of the typhous slate of collapse,
during peripneumonia or typhus, may be one of the provisions of nature
to allow the parts to recover, as they would during the collapse of syncope
produced by bleeding; and, of course, when so important an organ as the
brain itself is diseased, we should be careful how we set the heart pumping
more forcibly than necessary. Let us, however, not go into the opposite
extreme, and allow the patient to die for want of a spoonful, or even a
bottle, of wine or brandy, (for the quantity must be relative, depending on
the effect,) if there be real danger of sinking; and when the rallying point
is gained, caution is necessary not to push tliem too far. There is languor
and lassitude in all fevers, but the symptoms of sinking, requiring stimu-
lants, are, fluttering, weak, soft pulse; cold sweat; lying on the back; re-
spiration oppressed; involuntary dejections. Wine, on the other hand,
will not agree whilst the pulse is hard or sharp, and the skin decidedly
dry, even when there is subsultus tendinum and prostration. Ammonia
should be tried before resorting to wine.”

The whole of the remarks of our author in reference to the treatment of
typhus fever are in the highest degree judicious, and correspond with the
results of our own experience; we have room, however, for only the fol-
lowing extract in reference to this subject: —

“ The state of low or typhus fever being in reality debility, it is difficult
for the beginner to satisfy himself of the necessity, or even the safety, of using
depleting sedative remedies: nevertheless, all mAio have experience (except
the Brunonians) allow its expediency, in whatever way they may explain
it; and it is necessary to be as well assured as possible on this point. The
student can more readily be convinced of the necessity for depletion in a
state of complete prostration, produced by inflammation of the lungs, or
other organs, because he can understand the cause of that stale to be, that
the capillaries of the organ are over-loaded, and that by lightening them
their power of action may be restored. But the low fever being thought
to have no fixed habitation, and being considered as a something pervading
the system, the rationale of treatment is found not so evident. Fever per-
vades the frame, it is true, because the nervous system, which is its seat,
pervades it. The phenomena of idiopathic fever, show that the nervous
system is first implicated — debilitated by a morbid poison from the first:
hence the necessity for unloading the debilitated congested capillaries of
the nervous centres by sedative treatment. In addition to this, as post-mor-
tem examinations prove, that there is uniformly some visceral inflam-
mation in typhus, the expediency of an antiphlogistic treatment becomes
more obvious.”

In relation to the gastro-enteritic doctrine of fever. Dr. B. makes the
following remarks: —

“ The functions of the primae viae are so uniformly disturbed in fever,
whether symptomatic or idiopathic, that it is not surprising that Broussais,
an accurate observer, should have fixed upon the mucous membrane of the
stomach and bowels, as the seat of the immediate cause of idiopathic fever;
but I think I have shown, that fever is lesion of the nervous system —
if commencing there, idiopathic; if induced there by inflammation of other
organs, symptomatic. Some inflammations of the viscera arise during
fever, and are very truly said to be produced by the fever; that is, the organ
having been predisposed, when it is robbed of its due supply of nervous

159

Billing’s First Principles of Medicine.

energy, by the derangement of the functions of the nervous centres, its
vessels fall into the congested or inflammatory state; and when the cerebral
symptoms diminish, if not before, it is observed that some organ is afl’ected.
This is the case, most frequently, with the mucous membranes of the in-
testines and lungs in temperate climates, and with the intestines and liver
in hot climates; so that it is a doubt with many whether the fever has
brought on the hepatitis, or the hepatitis the fever; or whether the inflam-
mation of the mucous membrane, brings on the fever, or the fever the in-
flammation of the mucous membrane, as in acute dysentery. Sometimes the
disease in the first instance is the fever, but even then the brain has been
rendered more susceptible of the exciting causes of fever, by the previously
debilitated state of the organs — the liver, the bowels, or the brain itself;
and the moment the fever begins, the organ has its congested or inflammatory
slate increased, and so rendered evident, though it was latent previously.”

The congestion of the organs during the febrile state explains, according
to the author, the obstinacy of some agues. The cause which prevents
the cure of the ague is visceral disease, either existing previous to the
ague, or occurring during its continuance. The ague and visceral disease
act reciprocally as cause and eflfect— -the first aggravates the latter by caus-
ing congestion at each fit, and the visceral disease by keeping up morbid
sensibility during the intermissions, preventing the nervous system from
being cured by bark; but as soon as by bleeding, leeching, mercury, &c.,
the visceral disease is cured, the bark arrests the ague.

“ Considering disease, then, as depending on the conjoint affections of
vessels and nerves, and knowing what agents will influence their actions,
we may, says Dr. B., in our practice, always have a reason for the appli-
cation of remedies, and be able to combat such cases as we have not be-
fore seen or heard of. Acute diseases are those in which the feverish or
other constitutional symptoms are the most urgent, so as to threaten life.
Chronic diseases prove fatal only^when the gradual alteration of some
organ undermines the constitution by interrupting some of the nutrient
processes — as in decline, from disease of the mucous membrane of the
intestines, or from slow disorganization of the lungs, liver, &c.”

Dr. B. denies that there is any specific typhus fever, but on the con-
trary maintains that there is but one simple fever; and which is exanthe-
matous, petechial — that it is continued, synochous (synocha, whe-

ther with high or low pulse, high or low temperature — and that, when the
sensorium is oppressed in addition, it is typhous (typhus).

We had intended to present a short analysis of the author’s pathology
of the remaining class of diseases the neuroses, which according to him
consist of derangement of the nervous system, characterized by pain and
a tendency to spasmodic, convulsive, involuntary motion. But we find it
would be impossible to do this in a satisfactory manner without greatly ex-
tending our notice of the work; we shall merely, therefore, offer to our
readers the following extract, in which they will find, in the author’s
own words, a general summary of his pathological views of inflammation,
fever, and the nervous affections properly speaking.

“There will have been observed nothing of humoralism in the preced-
ing pages — for though I admit the influence of imperfectly assimilated
nourishment, and its consequent deterioration of the blood chemically, pro.
ducing gravel or scurvy, &c., I ascribe the effects, whether remedial o^
noxious, of agents, mineral, vegetable, or animal, taken into the circula.
tion, to their producing changes of the solids. All diseases^ in fact, com.

160

Reviews,

mence by disturbance of the function of the solid parts of the machine—
and first of all, of the nervous system. This is solidism, or neuro-patho-
logy. The nervous system, it is superfluous to repeat, regulates and sup-
plies all with energy. There is no organic sensibility, or organic con-
tractility, independent of the nerves. Every natural impression is re-
ceived by the nerves; every morbid agent is first felt by, and operates
upon the nerves. Inflammation of cellular tissue, bone, conjunctiva, &c.
through mechanical or other violence, result in consequence of injury to
the peripheral nerves ^nd to the capillaries — -fever from injury to the cen-
tres of the nervous system, which arises either from peripheral injury
propagated to them, or through lesion by miasma, which, by the route of
the circulation, directly poisons them; most probably by chemical combi-
nation and alteration — instantaneously lowering their power or energy.
I have shown that the immediate effect of the lowering of the power and
energy of the nerves, or the nervous system, is inflammation, or conges-
tion of the capillaries, the first degree of inflammation. The diseases of
morbid sensibility {neuroses) depend also either upon a partial or general
derangement of the nervous system — arising, when general, either from
the disordered state being propagated to the central organs from a dis-
tant region of the body, from a wound, in traumatic tetanus — a poison, in
hydrophobia — from the uterus, in hysteria, &c.; or originating there
through the gradual operation of a debilitating cause, as delirium tremens,
paralysis agitans, idiopathic tetanus, chorea, &;c.; or when general mor-
bid sensibility is suddenly produced by loss of blood or fright; — so that
neuroses, as well as fever, may be produced suddenly or gradually, and
like it, may be either idiopathic or symptomatic. Fever essentially de-
pends upon a diminution of the power of the nervous system — the nervous
influence whatever that be, is deficient — whereas the diseases of morbid
sensibility appear to arise, not from a^want of sensitive and motor-nervous
energy, but from a derangement of the "machinery of the nervous centre,
or a disturbance of that connection of the nervous centres with the nerves,
which not only induces, but regulates action. Thus, neither in tetanus
nor hysteria, is there deficiency of power either in the nerves or muscles — as
the morbidly increased sensibility, and the powerful spasms and convul-
sions show — but a derangement in the direction of it. In fever there is
a want of steam, or moving power, to use a mechanical illustration; in the
neuroses the machinery is out of order: for instance, when fever is fully
established, sensibilities of every kind are blunted, both what are called
animal and the organic; and there is debility also of the voluntary and
involuntary muscular systems. In the diseases of morbid sensibility, epi-
lepsy, tetanus, neuralgia, hysteria, chorea, hydrophobia, &c., either all
the sensibilities, animal and vegetative, are rendered morbidly acute, or
the motor energy is distributed to the muscles irregularly — if not too abun-
dantly, as we see in chorea and paralysis agitans, volition would guide the
hand to the mouth, but in consequence of the deranged nervous centre,
the hand is thrown in other directions in spite of the will, from the anta-
gonist muscles not being under its direction. Or the derangement of the
functions of the perceptions and volition, incidence and reflexion, is simul-
taneous, as in hydrophobia, and some cases of hysteria. In fever there is
abundant evidence of lesion of the cineritious tissue, interfering with its
function, the generation of nervous energy; in morbid sensibility we have
only an evidence of deranged actions in the distribution of it in the me-
dullary white tissue. In morbid sensibility we do not find the faculties of

161

Billing’s First Principles of Medicine,

the sensorium interfered with, unless when, in the advanced stages, a de-
gree of fever coming on, induces the delirium or coma of congestion — or,
on the other hand, inanition produces delirium, as in haemorrhage, delirium
tremens,” &c.

The remainder of Dr. Billing’s treatise is devoted to a very brief con-
sideration of the pathology and treatment of ague, cholera and influenza;
erysipelas and rheumatism, phthisis, catarrhs, dropsy, hemorrhages, and
chronic cutaneous eruptions. The very concise manner in which each
of these affections is treated of, may be inferred from the small space
devoted to them — seventy pages, printed in a large type.

Ague, according to the author, is essentially fever; forming, however,
a connecting link between fevers and neuroses, as a considerable degree of
morbid sensibility exists in it; and being closely allied to Asiatic cholera
and influenza, which Dr. B. likewise considers to be essentially febrile
diseases.

According to our author, in the first stage of all fevers, the chill is the effect
of the debilitating influence exerted on the nervous centres — the mind being
at this time clear though languid; the pulse small, the skin cold, and the
limbs tremulous or convulsed, from the morbid sensibility of the nervous
centres, evinced also by pain in the head and spine. From the weakness of
the circulation, all the external capillaries contract, and the blood is conse-
quently congested in the internal parts of the trunk, producing nausea,
and other disturbance of the primee viae, augmented “ by the morbid sen-
sibility of the sedatived nervous centres, sometimes causing vomiting and
diarrhoBa.” This stage of depression may last for minutes, hours, days,
or weeks, as evinced in the ephemeral, continued fever, regular agues, and
those irregular agues vulgarly called dead ague.

The next stage of fever, the hot, or as Dr. B. prefers calling it, the re-
laxed, arises from the relaxation of the nervous centres, consequent upon
their previous sedation. Upon the extent tp which this relaxation occurs,
will depend whether the fever will be hot or not; if the relaxation be so
great as to suspend the secretion of nervous influence, as in typhus, the
circulation and respiration will not have power to produce a full pulse and
hot skin; when the degree of relaxation is less, the skin will be hot and
flushed, as in continued fever and in ague. But in either case the skin
will be reinjected; for even in typhus fever, though the heart be weak, the
superficial capillaries, having lost their tone from deficiency of nervous
influence, relax, and are refilled, even by the weak heart, with a dusky
blood. And a similar state may be seen in some agues where, after the
chills, there is a typhous state, and a livid colour of skin, wdth dreadful
languor. Thus, even in ague, remarks Dr. B., the student must not ex-
pect to find always the hot stage of the nosologists.

These constitute, according to our author, the only two stages of fever
and ague. There is no third stage; the sweat which succeeds the hot
stage is, he observes, only an indication of renewed secretion by the capil-
laries, which, after having lost their tone, and been, consequently in a re-
laxed, distended, non-secreting state, renew their secretion on being re-
stored to a normal condition; and of course, as they are returning from a
relaxed state, they will pour out fluid sweat at first, until recontracted
sufficiently to secrete insensible perspiration only.

Ague, we are told, frequently degenerates into continued fever, w'hich,
when of the simple continued kincj, synochous, with hot skin, is called a
remittent; when of a typhous character, it assumes the form of dumb ague.

14*

162

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Ague constitutes the link, Dr. B. remarks, between fevers and neuroses.
In regular ague, constitutional morbid sensibility is prominent. There
exists, it is true, a great degree of congestion of the nervous system, as
well as of the viscera, during the paroxysm; but rarely, we are told, is
real fever produced. There is the pyrexia equivalent to what occurs in
hysteria, but seldom actual fever; not that loss of power in the capillaries
of the nervous system, which prevents the generation of nervous influ-
ence; for in ague, stimulants, unlike the effect they have in ordinary fever,
do not produce the coma of plethora — the nervous centres being little in-
jured, though debilitated, are relieved by the stimulant narcotic tincture of
opium; and consequently fresh energy is communicated to the capillaries,
even in the hot stage, by which they resist the heart’s injective force.

Dr. B. holds, that a relaxation of the capillaries is sufficient to explain
the production of dropsy, and he denies that it ever arises from a dimin-
ished action of the absorbents. Dropsy, he remarks, most generally re-
sults from a state of debility of the nervous system, and consequently of
the capillaries, induced by disease of some organ, and increased, as in
organic discharge of the heart, liver, lungs, &c., by mechanical obstruction
of the circulation.

Dropsy, Dr. B. conceives, may be caused by any protracted disease,
which, by morbid sensibility or slow fever, robs the secretory organs of
their nervous energy, as the kidneys, skin, and intestines, but particularly
the kidneys and skin. These ceasing to secrete, the redundant fluid oozes
from the capillaries, which are not merely overloaded, but weakened, in
consequence of the deteriorated state of the nervous system; and unless,
the author remarks, we can restore energy to the nervous system, so as to
check exudation, by giving tone to the capillaries, we in vain resort to
tapping, or diuretics, or cathartics, such as elatereum, to evacuate the drop-
sical fluid, as it will speedily reaccumulate. Thus, he adds, dropsy is not
to be treated as an isolated or single disease, except where for a time, to
prevent a patient from being overwhelmed by the fluid in the cavities, we
turn our whole attention to getting rid of it, either by tapping or by in-
ducing profuse serous evacuation from the bowels or from the kidneys.

Dr. B. considers, that hemorrhage from the mucous membranes, as well
as purpura and purpura hemorrhagica, takes place under the same circum-
stances as dropsy; the exhalents from atony, and sometimes from over-
repletion, as in epistaxis, allowing blood to exude instead of aqueous fluid.
Even the capillary exhalents of the serous membranes sometimes allow
blood to escape, which is found mixed with the dropsical lymph upon
tapping, or after death.

But we must here stop. We have presented a sufficiently extended
notice of Dr. Billing’s Principles of Medicine, to enable our readers to
form a general idea of the pathological and therapeutical views, by which
his work is characterised. However much we may be forced to differ
from these in many of their most important particulars, we must, never-
theless, as already remarked, concede to them the character of very great
ingenuity and plausibility. At the same time, we do not consider the
work before us as destitute of a high degree of excellency; much that the
author has advanced, as well in regard to the nature and character of mor-
bid phenomena as to the curative action of remedies and plans of treatment,
bears in our estimation the seal of truth, and will be found to be borne out
by the results of experience. He deals largely, it is true, in mere hypo-
thetical reasoning; he has, nevertheless, combined with this many excel-
lent practical hints, of which the young as well as the more advanced
practitioner may make a very profitable use. D. F. C,

163

BIBLIOGRAPHICAL NOTICES.

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hange iiher die Verpjianzung der hornhaut, Keratoplastik. Nach eigenen Ver-
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burg. Marburg, 1833, 8vo. pp. 144.

On the Formation of an Artificial Pupil in the Sclerotica, with an Appendix on
the Transplanting of the Cornea. By Dr. B. Stilling, &c.

The idea of forming an artificial pupil, by removing a portion of the sclero-
tica and subjacent coats of the eye, and thus allowing an entrance to the rays of
light into the interior of the eye, in those cases of blindness in which the cor-
nea and iris are completely disorganized, while the remaining structure of the
eye, with the exception in some cases of the lens and its capsule, are unaflfect-
ed, appears first to have suggested itself to Autenrieth in the year 1814.

In the month of June, of this year, a female nine years old, was admitted
into the hospital at Tubingen, who, in early infancy, in consequence of the
small-pox, had lost the sight of both her eyes. The pupils were closed; the
anterior chambers W'ere obliterated, in consequence of an adhesion of the iris to
the posterior surface of the opaque and contracted cornea. On the edge of the
cornea in one eye, there remained a small transparent spot, but altogether in-
sufficient to warrant any hope of success from the formation of an artificial
pupil by the separation of the edge of the iris from the ciliary body. The
eyes of the girl were in other respects uninjured, and when her face was turned
to the sun, she was able to distinguish a very slight degree of light.

In contemplating this case, the idea occurred to Autenrieth, that if an artifi-
cial pupil could be formed through the sclerotica and choroid coat, sight might
be restored to the patient and to all others similarly circumstanced.

Accordingly a series of experiments upon rabbits and other animals were
performed; the result of which proved very satisfactorily, that a portion may be
cut out of the sclerotica and subjacent coats of the eye with perfect safety; that
the vitreous humour slightly projects at the opening, and that the small tumour
thus formed becomes covered with a thin semi-transparent membrane, consti-
tuting a kind of vicarious cornea, through which the rays of light pass into the
interior chambers of the eye, and give rise to a certain extent of vision.

The experiments alluded to show also, however, that in all probability, but a
very imperfect degree of vision can be restored by an artificial pupil formed in
the sclerotica — that although the covering membrane of this artificial pupil is
at first tolerably transparent, there is a danger of its becoming subsequently
opaque, and in this manner destroying the benefit of the operation; and finally,
that it is not entirely certain that in the human subject the vitreous humour may
not escape entirely through the opening formed through the coats of the eye, or
a severe inflammation be induced, by which either the whole eye would be de-
stroyed, or at least a thick layer of -coagulable lymph effused so as to close
up the artificial pupil.

These serious objections to the proposed operation, our author has very inge-
niously, but in our opinion, unsuccessfully, attempted to remove. He admits,
however, the very imperfect degree of vision obtained by the operation, even
when most successful; which we grant would not be a very valid objection to it,
in the cases to which it is alone applicable, could we depend upon its very gen-
erally succeeding in all other respects.

A variety of additional experiments, with the view of perfecting the opera-

164

Bibliographical Notices*

tion, were subsequently made by Autenrieth, Schmid, Gartner, Weber, Riecke,
Moesner, Muller, Uilmann, Ammon, Hiiter and the author.

Riecke appears to have been the first who attempted the operation on the hu-
man subject, in a sufiicient number of cases at least, to test its feasibility and
real value — the result of his experience is by no means however very en-
couraging’.

The following is an outline of the cases in which the formation of an artifi-
cial pupil in the sclerotica was undertaken by this gentleman, as described in
the work before us.

In 1817, the operation was performed on a female twenty years of age, who
after an attack of small-pox in her third year, had remained entirely blind, and
was at the same time labouring under chlorosis and a high degree of nervous
asthenia. On the fourteenth day after the operation, there was discovered at
the spot where the sclerotica was perforated, a small transparent tumour contain-
ing a projecting portion of the vitreous humour. Through this the patient was
able to distinguish the faces of the by-standers, although somewhat distorted
from their natural appearance. In the course of four Aveeks, the covering of the
artificial pupil became somewhat obscured; it was not, however, even at a still
later period completely opaque, and continued to afford the patient a partial
vision.

In 182Q, the operation was performed, first, on a robust country girl, who had
become blind from small-pox in early youth. On the eighth day subsequently,
the opening through the sclerotica was entirely closed, in consequence of the
firm adhesion of its edges. Secondly, on an individual thirty years of age, who
had been blind from youth, in consequence of small-pox; on the fourteenth day,
the conjunctiva of the upper eyelid was found to be united with the portion of
the sclerotica at which the operation had been performed. Thirdly, on a boy
fifteen years old, who seven years previously had been rendered blind by an at-
tack of scarlet fever; on the fourteenth day, not the least trace of transparency
remained in the membrane covering the opening through the sclerotica.

In all the foregoing cases, the conjunctiva was removed, in the formation of
the artificial pupil, in common with the sclerotica, the choroid, and retina. In
the two following cases, the conjunctiva was separated from the sclerotica at
the spot where the operation was performed, previous to the^ removal of the
latter, and subsequently applied over the opening.

In 1822, the operation was performed on a female eighteen years of age,
blind from early youth, in consequence of small-pox. An entirely transparent
vicarious cornea was formed. Between the tenth and fourteenth days subse-
quent to the operation, the patient saw very distinctly the outlines of large ob-
jects. Three weeks afterw^ards, however, the muscles of the eye became affect-
ed with severe spasms, and the projecting transparent membrane of the artificial
pupil was burst; the humours of the eye escaped, and its coats collapsed. At the
end of two weeks, the ball of the eye was filled up to its original size, but no
trace remained of the artificial pupil.

The same year the operation was also performed on a female thirty years of
age, who had been blind from her youth, in consequence of the small-pox.
A beautiful round pupil w^as the result, through which the patient was able to
distinguish the outlines of any large object. In the course of three weeks, the
covering membrane of this artificial pupil began to lose its transparency. Com-
plete opacity did not however occur; and several months subsequently, the pa-
tient was able to distinguish light and darkness to a much greater degree than
she had been previous to the operation.

From the results of the foregoing cases, Riecke has drawn the following
general deductions.

1. Notwithstanding the preservation of a portion of the conjunctiva, to form a
covering to the opening made through the sclerotica and subjacent coats of the
eye, is an important improvement in the operation, yet the history of the first
four cases, as w^ll as numerous experiments on animals, shows, that the artifi-
cial pupil, without the covering of the conjunctiva, often remains for a conside-

165

Stilling on Artificial Pupil in the Sclerotica.

rable time transparent. Even when an opaque layer of the conjunctiva forms
over the opening made in the sclerotica, this may be often removed by a knife
or scissors, so as to restore transparency to the artif cial pupil. To secure the
portion of conjunctiva over the part operated on, it is better, according to Rieche,
to attach it by a suture.

2. It is absolutely necessary that the opening through the coats of the eye
be perfectly circular and not too small, in order to prevent the junction and con-
sequent adhesion of its edges. To form such an opening, he prefers a double
edged curved staphyloma knife.

3. In order that the operation may be successful, in every case, a slight pro-
jection of the vitreous humour must be produced. In the lower class of animals,
this occurs readily of itself, in consequence of the pressure of the strong mus-
cles of the eye, but in man, pressure on the ball of the eye will be necessary to
cause and maintain a sufficient projection of the vitreous body.

4. The formation of what has been termed a cornea succenturiata is very much
to be doubted. The wound in the sclerotica is not closed by a transparent cica-
trix, it being occupied completely by the hyaloid membrane.

5. The transparency of the hyaloid membrane always becomes somewhat di-
minished, but it never becomes as opaque as the sclerotica. The discovery of
the means capable of preventing this loss of transparency, is much to be desired,
in order to the perfection of the operation.

6. In reference to this operation, the change which occurs in the conjunctiva
subsequent to ophthalmia scarlatinosa^ as in the fourth case referred to above, de-
mands particular attention; in all the other cases, where blindness was the re-
sult of srriall-pox, the conjunctiva was entirely unchanged from its normal con-
dition.

The operation for the formation of artificial pupil in the sclerotica, was per-
formed subsequently by J. B. Muller, but without any permanent benefit; and
in 1827, it was performed by Professor Ullman. The patient, a man thirty-three
years old, blind from his sixth year, in consequence of a wound of the right
eye, and a subsequent hypopium of the left eye. For a short time subsequent
to the operation, the patient enjoyed, to use the words of our author, “ as perfect
a degree of sight as under the circumstances of the case could be expected;”
but finally, the artificial pupil was completely obliterated, and the patient re-
duced to a state of perfect blindness.

In the two or three instances in which the operation was performed by Pro-
fessor Ammon, it was attended with scarcely more beneficial results. As de-
ductions from the cases operated on by the latter gentleman, we are presented
with the following.

1. That neither the form of the eye nor the sensibility to light which still
exists in the diseased eye, suffer any prejudice in consequence of the operation
for forming an artificial pupil through the sclerotica; on the contrary, in a few
cases, the patients were of opinion, that in the clear light of day or in an artifi-
cial light, their power of vision was increased by the operation; this was par-
ticularly observed in a case in which the patient in consequence desired that the
operation might be performed on both eyes. It is worthy of remark, that the
excision of a portion of the sclerotica scarcely ever induces any inflammation
of this membrane — in no one of the cases in which the operation was perform-
ed by the Professor, was a trace of it observed — and all three of the patients
were able to use their eyes on the first, second and third days after the Opera-
tion.

2. The operation for the formation of an artificial pupil through the sclero-
tica, does not deserve the oblivion in which it has already fallen. It has been
too soon and rashly condemned, before the result of extensive experience as to
its worth could be obtained.

After presenting a very full, candid and interesting account of the observa-
tions and experience of others in reference to this operation. Dr. Stilling next
gives the detail of his own repeated experiments, the general results of which
are thus summed up.

166

Bibliographical Notices,

1. In the formation of the artificial pupil, it is necessary to remove a portion
of the conjunctiva as well as of the sclerotica, chorioidea and retina. By re-
taining the first, we endanger the transparency of the vicarious cornea.

2. The form of the excised portion of the above coats of the eye should be
either square or circular; a triangular opening is apt to close by the adhesion of
its edges.

3. The artificial pupil is most appropriately formed partly in the sclerotica
and partly in the cornea — a portion of the latter, with the iris and corpus ciliare
being removed at the same time with a portion of the remaining coats of the
eye.

4. The membrane covering the artificial pupil is not the original conjunctiva,
nor is it proper it should be, but is formed by an effusion of coagulable lymph
from the wounded edges of the sclerotica.

According to our author, the operation is proper in all cases in which the
cornea and iris are become completely disorganized; when the iris is adherent
to and inseparable from the cornea, or when the anterior or posterior chambers
of the eye or both of them are filled with an opaque exudation which cannot
be removed — and when at the same time the remaining structure of the eye, the
retina, choroidea, and sclerotica are unchanged from their normal condition.

The operation is contraindicated in cases of amaurosis, atrophy of the globe
of the eye, synchysis, hydrops bulb, varicositas oculi, deep-seated constitu-
tional disease, and all other conditions of the eye, as well as of the entire or-
gasm in which the operation for cataract is contraindicated. The operation is
likewise contraindicated when one eye only is diseased in the manner above
described, provided the other is still unaffected. For even when the operation
is the most successful, the disturbance of vision caused by the operation,
may affect injuriously the sight of the sound eye — and the consequent defor-
mity can scarcely be relieved by the use of glasses, as Schmid supposes.

The manner of performing the operation preferred by our author, is thus de-
scribed by him.

The instrument required is one invented by Bunger; it consists of three lan-
cet-shaped blades, fastened in the extremity of a square handle, in such a man-
ner as to be perfectly firm, but at the same time readily removed when required.
The largest blade is placed horizontally; it is sharp on both of its edges — the
two other blades are placed perpendicularly, one on each edge of the horizontal
blade; forming with the latter a kind of square trough — their points recede from
six to eight lines behind that of the horizontal blade, and are covered by a small
projection on the sides of the latter; the cutting edges proceed upwards, and
are of an ovoid shape. All the blades gradually increase in breadth from the
point towards the handle. The greatest breadth of the horizontal blade, at the spot
where the points of the perpendicular blades commence, is from two to two and
a half lines; and the greatest height of the perpendicular blades is the same.
Besides this instrument, a Daviel’s scissors and a forceps will sometimes be re-
quired, to remove any shreds of the conjunctiva or choroidea which may hap-
pen to present themselves at the edges of the opening.

The size of the portion to be excised from the coats of the eye should be
about two to two and a half lines in diameter, whether square or round. The
excision of a larger portion will endanger the prolapsus of the lens, or at least
of too great a portion of the vitreous humor, v/hich, if possible, is to be avoid-
ed, as the consequent collapse of the eye, by causing the edges of the opening to
approach each other and to adhere, will be apt to destroy all the benefit of the ope-
ration. If the portion removed, on the other hand, be too small, the field of
vision will be too much circumscribed, and even should the opening not be ob-
literated by adhesion of its edges, the benefit to the patient from the operation
will be trifling.

Dr. Stilling prefers the formation of the artificial pupil, partly on the cornea
and partly on the sclerotica, on the side corresponding with the outer angle of
the eye, The centre of the portion to be excised being marked by the point at

167

Stilling on Artificial Pupil in the Sclerotica.

which a line passing through the horizontal diameter of the pupil is crossed by
another passing perpendicularly along the inner edge of the cornea.

The patient is to be placed as in the operation for cataract, his upper eyelid
being raised by an assistant. The surgeon holding the instrument by the handle
between his thumb, index and middle fingers — the thumb being applied on the
upper, and the two fingers on the lower side of it — so that the edges of the up-
right blades are presented upwards, rests his little finger on the patient’s cheek-
bone, and with the index finger of the free hand, draws down the under eye-lid.
The patient being directed to turn his eye towards the inner angle, the point of
the horizontal blade of the instrument is to be introduced perpendicularly into
the sclerotica, at a proper distance from the cornea, and passed through all the
coats of the eye to the vitreous humour; the handle is then to be turned towards
the temple, so as to bring the point of the blade beneath the coats of the eye,
between which and the vitreous humour, it is to be passed about two and a half
lines in the direction of the cornea, when it is to be again passed out through
the iris and cornea; which will the more easily be effected if the horizontal
blade is slightly curved upwards. The edges of the upright blades are now
presented against the upper and lower angles of the external wound, and by
pushing forward the instrument, cut out a square portion of all the -coats of the
eye, between the two incisions made by the horizontal blade. The blood being
now gently washed away from the eye, any shreds of the membranes that may
remain attached to the edges of the wound are to be seized wfith a forceps and
removed by means of a Daviel’s scissors. The patient is to be confined to a
darkened chamber, his eye being covered with alight simple dressing. Care is
to be taken to prevent the occurrence of inflammation, and if any symptoms of
the latter occur, they are to be combatted with the usual remedies.

So far as the mere excision of the coats of the eye is concerned the described
operation, when carefully performed, is entirely without danger, or any serious
inconvenience. But in reference to its value as a means of restoring a useful
degree of vision to the blind in certain cases, there are many circumstances,
which, according to the admissions of our author, who is its professed advocate,
render this extremely problematical.

When most successful, the transparency of the membrane covering the artifi-
cial pupil, is always more or less imperfect, and, consequently, from this cir-
cumstance alone, the degree of vision it admits of, is always trifling and obscure.
In the most favourable cases, the patient is only able to distinguish between
day and night, or the most striking colours, &c., of the largest objects; but more
generally, he can distinguish only between light and darkness. The imperfect
refraction of the light, from the want of a crystalline lens behind the artificial
pupil, by which the patients are rendered myopic, detracts also from the value
of the operation, as it is hardly possible to remedy this defect by artificial means.

When after the formation of an artificial pupil through the sclerotica, a tolera-
ble degree of vision has been restored; this has become soon diminished, and
finally, entirely destroyed by the more or less gradual destruction of the trans-
parency in the closing membrane of the pupil — and although this may in some
cases be obviated by the removal of the opaque membrane, there is still a dan-
ger of the one subsequently formed, becoming in its turn likewise opaque.

In one case at least, in which the operation was performed on the eye of a
dog, a severe inflammation was induced, followed by suppuration, and finally,
bursting of the globe of the eye. Hydrophthalmia was also induced in another
instance; while a thickening of the conjunctiva with the development of
large vessels, similar to pterygium occurred in two instances. In one instance,
an adhesion took place between the conjunctiva palpebrse, and the wound in the
sclerotica; and amaurosis was of frequent occurrence after the operation — more
especially, however, when in performing it, the eye was dragged forcibly for-
wards, and otherwise roughly handled.

Whether future and more extensive experience will enable us to improve this
operation so as to render it of more advantage in the first instance, and to prevent
the occurrence of the unfortunate results above attended to, must, of course, be
left for time to determine.

188 Bibliographical Notices,

In the Appendix, Dr. Stilling presents a brief account of his experiments on
the transplantation of the cornea. He found that if in the eye of a rabbit, an arti-
ficial pupil is made through the sclerotica, and immediately a portion of the
cornea, cut from the eye of another rabbit, is accurately applied so as to cover
the artificial pupil and retained in its place by a delicate suture, it will adhere
without losing to any great extent its transparency. In one case, the trans-
planted cornea remained unchanged for six months. How far the transplant-
ing of the cornea of a brute into the human eye will succeed, and what amount
of advantage is to be derived from the operation, the facts detailed by our author
are insufficient satisfactorily to prove. D. F. C.

Art. XV. Appreciation de la Doctrine Phrenologique ou des localisations des
Facultes Intellectuelles et morales, au Moyen de V Anatomic Comparee, Par M.
Jules Lafargue, ancien interne des hopitaux.

An appreciation of the Phrenological doctrine, or the localisation of the intellectual
and moral faculties, by means of comparative anatomy. By M. J. Lafargue.

The article, the title of which is given above, is contained in the Archives
Generates de Medicine for March, April and June, 1838. It formed originally a
part of the memoir addressed by M. Lafargue to the Society of Medicine of
Bordeaux, in reply to the prize question proposed by that body — “To determine
by argument, by comparative and pathological anatomy, and by physiological
experiments, what is positive in regard to the localization of the functions of the
Brainl’^

The author has attacked the doctrine in all its details. He has attempted to
show by an examination of the heads of the various verteb rated animals, and a
comparison of their respective forms and dimensions, that the localization of the
functions of the brain, or to speak more accurately, the localization of the phre-
nological organs as taught by the advocates of thatdoctrine, is altogether untrue.
And really, if we are to receive the statements of M. Lafargue as established
facts, and admit the validity of his deductions, the article before us can be
viewed in no other light than as a complete and satisfactory refutation of the
doctrine of phrenology.

The accuracy or inaccuracy of the author’s alleged facts, and of his leading
inferences, can only be established by a careful examination and comparison of
the skulls of the different classes of animals. By cautiously noticing the pecu-
culiarity of conformation of the head in the individuals of each class or species,
and comparing this with their known habits and disposition, we shall very
speedily discover whether the views of M. Lafargue, or the Doctrines of Phre-
nology have their foundation in nature.

According to M. Lafargue, Phrenology cannot be true. Because —

" IsL In certain classes of animals, the pachydermata for example, the form of
the brain cannot be determined by that of the external skull.

^dly. In the mammalia, the form of the cranium and of the brain is altogether
dependent upon the mechanical organization of the skeleton, especially in refer-
ence to the mode of station, progression, and mastication of the animals.

^dly. The development of the occipital crest is in exact proportion with the
height of the animal, and the weight of the face — that of the interparietal is in
direct proportion to the strength of the jaws, and in inverse proportion to that of
the brain.

Athly. Hence, in all the individuals of different groups or species of animals,
the conformation of the cranium is the same; thus animals whose habits and
dispositions are precisely similar, differ in the conformation of their heads, from
the difference in their attitudes and mode of mastication, while those whose
liabits and dispositions are dissimilar, resemble each other in the form of their
skulls and brain, because their attitude and mode of mastication are alike.
bthly. Whenever any one portion of the brain is more or less developed, there

Lafargue on Phrenological Doctrines, 169

will be found a proportionate greater or less development of every other portion
of the organ.

The following extract from that section of M. Lafargue’s Memoir which
treats “ On the Relation between the form of the Cranium and the moral habits,”
will enable our readers to judge of his manner of treating the subject he has
. ’-^^taken to investigate —

' ' ' ouse and the rat, having the head broadest posteriorly, should, accord-
'’nologists, experience to a greater extent than the other mamma-
■ love of habitation. If it is difficult to prove the falsity of this
.;.ii ou.'* imperfect acquaintance with the disposition of the mouse and
'liiif, yet is it possible to sustain it otherwise than by a hypothesis'? But the form
of the cranium and of the brain in these animals, is explained by a fact less ob-
scure than their moral habits— namely, by their mode of station which is evi-
dent to every eye.

“ All the glires or gnawing animals have not, however, a conical head; thus
the rabbit and hare have one shorter, and in some degree more globular — it is
broader from one temple to the other, and resembles more in every respect that
of certain of the carnivora. Hence, those animals ought to exhibit courage and
ferocity, while every one knows that they are mild and timid. Who does not
know, on the contrary, that certain individuals of the rat-kind, the form of whose
craniums indicates the possession of the benevolent affections, devastate the
dove-cotes by destroying the young birdsl Who is not aware of the ferocity of
the field-mouse and hamsterT Even distrusting the exaggerated reports of cer-
tain German naturalists, we do not hesitate to believe in the warlike and san-
guinary disposition of the last-mentioned animal, the temporal region of whose
skull is, nevertheless, very much depressed.”

“ The cranium of the beaver is distinguished by its breadth from one temple
to another and its depression in other parts, so that the destructive organs should
have in this animal a considerable development, and yet who has ever pretended
that the beaver was a sanguinary animaH”

“ Buffon does not describe it as a sanguinary animal, but he affirms that it
cuts or saws, in some manner, with its incisor teeth, the largest and most resis-
tant branches of trees, which implies a great power of mastication. In the
beaver, the inferior jaw being, in fact, as strong and broad at its basis as in car-
nivorous animals of a similar height, the bitemporal diameter of the cranium
should necessarily have the same extent.

“ If the cranium of the beaver contradicts the pretended seat of destructive-
ness, it gives a formal contradiction likewise to the localizers of the faculty of
constructiveness, in as much as the depression of the external portion of the
frontal bone is in contrast, in this animal, with the projection of the temporal re-
gion; and yet, the beaver is distinguished by habits of industry as the carnivora are
% their ferocity. As well for the constructive as for the sanguinary habits, there
is required a powerful instrument, a broad and strong jaw. Hence to favour the
constructive as well as the destructive instinct, the temporal regions enlarge and
allow thus for the articulation of the inferior jaw and for the insertion of the tem-
poral muscles.”

“ In regard to the carnivora, we have already remarked that the cranium of
the polecat and weasel is broad behind, and narrow towards the temples; now
will any one ever pretend that these animals are very much given to the senti-
ment of friendship! The domestic ferret never attaches itself to its master,
whom it bites whenever it has an opportunity; hence all sportsmen handle it
with caution. No one will pretend that the ferret is not sanguinary, and yet the
flatness of the temples is in contrast with the breadth of the posterior part of its
skull.”

“ The form of the cranium of the weasel and ferret, so opposed to phrenology,
is very readily explained by the mechanism of their bodies, when we consider
that these little animals having, as the mouse, short extremities, require to have
the skull elongated, broad behind and narrow towards the temples. This expla-
nation is the more firmly established by the fact, that certain of the carnivora
No. XLVII.—May, 1839. 15

170

Bibliographical Notices,

analogous, in many respects, to the weasel and ferret, but having an attitude more
elevated, approach, in the shape of the cranium, to the fox and greyhound, as the
polecat, the marten, and the otter. In proportion as the animal is elevated from
the ground, the head becomes shorter, and swells out in the sus-zygomatic region.
The latter is more depressed in the ferret and weasel, than in the rabbit and the
beaver; yet the first two, as ferocious as the tiger, destroy beyond their wan+‘^'
but as they walk with the belly nearly touching the ground, it is reai”'^‘
their head should be broad behind, and narrow towards the temn^
same with certain of the rat kind of a very ferocious disposition
and hamster. All these species have a lower jaw, of which mo
np for its deficiency in breadth; so that notwithstanding its narrowness, i.. _
ference to the temples, it can easily articulate itself at the base of each of the
zygomatic apophyses.”

“ In the carnivorous types, the details in regard to the form of the cranium,
are explained by the attitude of the body as well as by the strength and breadth
of the lower jaw. The lion, the wolf, and the cat are remarkable for the savage-
ness of their disposition, of which the manifestations vary only in degree; but with
these variations, let it be remarked, we do not observe a corresponding difference
in the prominence of the temples compared with the other parts of the cranium;
thus the shock-dog and the hyena have the same development of the organs of
murder and of courage.”

“ In passing to the ruminating animals, we observe a class in which the form
of the cranium, although very different from that of the carnivorous, is invariably
explicable from the circumstrances relative to the mechanism of mastication.
The wild or domestic animals of this class are, for the most part, mild, peacea-
ble, and inoffensive; some, however, are more courageous and more ferocious
than others, but without any corresponding difference in the form of their brain:
as, for instance, the buffalo and bull. I have already said that the cranium of
the camel {camelus hadrianus) does not resemble that of the other ruminating
animals; it is distinguished from them, by the presence of an interparietal crest,
and by the length of the bitemporal diameter; according to the doctrine of phre-
nology, it should, therefore, be more warlike and ferocious than the buffalo —
whereas of all the ruminating species, it is the one that was the most easily do-
mesticated, because it is naturally the most mild and docile.”

“ In the adult of the mammalia, the size of the cerebellum follows always that
of the cerebrum, from which it results, that in all of these animals the generative
impulse should have the same relative force.”

“All birds have a large cerebellum, and the cock is not more favoured in this
respect than the others.

“Among fish, in the silurus, which does not copulate more than the others,
the cerebellum predominates over the rest of the brain.”

We have room only for the general conclusions drawn by the author, from
the facts and deductions set forth in the article before us: —

“1. In analogous species of animals^ the form of the cranium. Indicating
the respective developments of the brain and face, measures their moral and intel-
lectual perfection, and consequently their ferocity, which is in inverse proportion
to this perfection — this results from a comparison of the tiger and spaniel. But
among certain distant species, there are differences in the form of the cranium
and brain, although the dispositions are the same, arising simply from a diver-
sity in the mechanical construction of their bodies, either general or local, as
may be observed by comparing the wolf and the weasel, the beaver and the cal,
from whence it arises that the anatomy of the mammalia is opposed to the
localization of the faculties.

“ 2. The form of the cranium in the different races of men, indicating the re-
spective size of the brain and the face, measures the extent of intelligence as a
whole. When two varieties of our species are distinguished, the one by the
elevation of the faculties and of the higher sentiments, the other by the prepon-
derance of the grosser propensities, the cranium is found to be uniformly large
in the first, and uniformly contracted in the second. But the parietal vault, the

Lafargue on Phrenological Doctrines.

171

frontal region, and zygomatico-mastoidien regions preserve the same relative
proportions in both, from which it results that the anatomy of the human race is
opposed to the localization of the faculties.

“ 3. The major part of the skulls of murderers, thieves, and poisoners, found
in the collection of Gall, have not a form different from the medium conformation
f the cranium of the white race, as we have demonstrated by an exac-t measure-
* '^mall number present the form desired by the phrenologists; but as
■ "md this form in individuals of the mildest disposition, with a
brain, we hence conclude that it is not peculiar to thieves,
rrom which it follows that the comparative cranioscopy of in-
Givxuuals of the same race is opposed to the localization of the faculties.

“ It only remains for us to bring together our three means of refutation, in
order to appreciate their respective value. Gall and his followers, perceiving
how much their system would acquire strength by the sanction of analogy, have
not neglected to interpret, in their favour, the form of the head of certain of the
mammalia. Thus, when the alleged peculiarities of configuration in the head of
a murderer do not produce entire conviction in the mind of a sceptic, they endea-
vour to attain their end by appealing to comparative anatomy; they insist upon
the proportions, so remarkable, of the brain of the carnivora and the herbivora.

“ We observe among men of the same race differences of intellect so trifling,
that we might almost invariably attribute them to exterior influences, which the
phrenologists do the more willingly, as the resemblance of the heads of the same
type allow rarely any peculiarity of form explanatory of the peculiar character
of the individuals to be seized upon. But, in examining each variety of the
human race in general, we find, on the one hand, the native faculties delineated
by striking features in the moral habits; on the other hand, a medium conforma-
tion of the head characterized as the distinct type; so that if there exist between
the races moral and anatomical differences, they will both be equally decided
and easy to appreciate; now all these differences do exist, but they do not corres-
pond in such a manner as to justify the localization of the faculties.”

We have presented the foregoing notice of the memoir of M. Lafargue, not
because we are of opinion the author has succeeded in overthrowing the doctrine
of phrenology, or that all the objections to its truth which he has brought for-
ward cannot be readily and very satisfactorily met, but because we conceive that
M. Lafargue has indicated the only possible mode in which the truth or falsity
of phrenology can be established — the minute study of the conformation of the
cranium and brain in all the various species of vertebrated animals, especially
of the mammalia, and of the most striking differences observable upon an accu-
rate comparison of them with each other; a cautious observation of the peculiar
habits and dispositions by which each species or variety of animals is distin-
guished, and whether any peculiar conformation of brain is invariably connected
with any predominant habit, disposition, or propensity. It is neither by the
metaphysical arguments, nor by the misrepresentations or ridicule of the prin-
ciples and tendency of the principles of phrenology, that have, heretofore, almost
invariably been made use of in attacking it, that its overthrow can be accom-
plished— this can be done only so soon as it shall be proved to be in opposition
to the facts based on the true anatomy and physiology of the animal frame.

D. F. C.

172

Bibliographical Notices.

Art. XVI. Die Gefdssdurchschlingung. Dine neue methdde, Blutungen aus
grosseren Gefdssen zu Stillen. Von Dr. B. Stilling, prakt arzt zu Cassel.
8vo. pp. 153, Marburg, 1835.

Die naturlichen Frocesse bei der Heilung durchschlungener Blutgefdsse mil beson-
derer Rucksicht auf den Thrombus. Aus einer grossen reihe Von Versuchen an
Thieren abgeleitet. Von Dr. B. Stilling. &c. 8vo. pp. 304, Eiseiiac> ”
Geschichte einer amputation des oberschenkels, wobei die durchschlins"’
fem.^ art. prof. fern, und der vena fern, in anwendung gezr'

Dr. B. Stilling, &c. 8vo. pp. 32, Hanover, 1837.

The three works, the titles of which are given above, have reference to a new
process invented by their author. Dr Stilling of Cassel, for the arresting of he-
morrhage from the large vessels, whether arteries or veins, when these have been
divided by an accidental wound or in operations, as well as for the obliteration
of large blood vessels in cases of aneurism, &c. The process consists in car-
rying the divided extremity of the vessel upwards and passing it through a loop
cut in its side, a short distance above the division.

This operation, when skilfully performed, is described as a perfectly secure
means for arresting hemorrhage and as affording a more certain security agairjst
secondary hemorrhage than either the ligature or torsion. It is, however, in the
language of Professor Hertwig, more difficult of execution, requires a more firm
and skilful hand, and greater accuracy of vision than the ligature or torsion, and,
also, occupies more time. It is, likewise, liable to have its success impeded or en-
tirely destroyed by a greater number of trifling circumstances than is the case in
either of the other methods for arresting hemorrhage; — it requires too for its ac-
complishment a larger portion of the vessel to be laid bare — it is represented
nevertheless as inflicting less injury upon the vessel and less irritation upon the
surrounding parts, and consequently as presenting a less impediment to the
speedy union of the wound in the soft parts than the ligature or torsion.

It may be readily executed, we are assured, on all blood vessels, which have
more than aline in diameter, and it is to be preferred, in injuries of the larger
arteries, where an immediate union of the external wound is desirable, as in
wounds of the abdomen and of the protruded bowels, in punctured wounds that
can be freely enlarged, and in all cases indeed in which the divided vessel lies su-
perficially; it being absolutely necessary in the operation under consideration that
the entire end of the wounded vessel be completely v/ithin sight. On the other
hand, the operation, we are told, cannot well be performed and is not to be recom-
mended, as a general rule, in vessels of a less diameter than one line; in the
larger veins; in deep seated vessels; especially when the external ’wound is
small in extent; in such vessels as are liable to retract, when wounded, within
bony channels; in vessels the parietes of which are hardened or ossified, and
finally, in any case in which the life of the patient will be endangered unless
one or more bleeding vessels be promptly secured.

In the first named of the works before us the operation is minutely described
— of this description we present the following summary.

The instruments required, where the operation is to be performed on a divided
artery, are, a common anatomical forceps, with tolerably broad points, a com-
pression forceps, a spear pointed knife, a small forceps with slender points,
slightly curved, and a thin blunt probe.

When the vessel to be operated on is undivided, in addition to the above in-
struments, and those necessary to lay bare the vessel, there will be also required
a second compression forceps, and two ordinary forceps, to hold the deep seated
ends of the vessel after its division. The forceps with which the end of the
artery is carried through the loop in its side, must correspond with the diameter
of the vessel, hence it is necessary that the operator be provided wdth several
of different sizes.

When the vessel has been divided b)r an external wound &c., the end of it is to
be drawn out somewhat as in the application of a ligature, and a compression

173

Stilling’s New Process for arresting Hemorrhage,

forceps applied upon it, at the distance of rather more than twice its diameter,
from its open end. If the end of the artery is covered with a considerable
amount of thick cellular membrane this is to be separated with a forceps or
knife. The operator with a forceps now seizes the vessel transversely near its
divided extremity, and renders it flat and tense. He then transfixes the vessel
'flth the spear pointed knife, at about half a line to a line according to the size
"ory, from the edge formed by the flattening of its coats, and in this
an incision through both its sides, in the direction of its long
to the diameter of the vessel and beginning about the
, . ,o aoove its divided end. Through the loop thus formed in the side

ot the vessel, the points of a slender forceps are to be introduced from below,
and passed out a short distance beyond the loop on the upper surface of the vessel.
The second forceps may now be removed and the blunt end of the probe being
introduced about one or two lines within the cavity of the vessel at its divided
extremity, by its assistance a fold of the latter is to be carried upwards, so as to
enable the points of the forceps passing through the loop to seize the greater
part of the circumference of the divided extremity, which, by the careful with-
drawal of the forceps, is to be carried by them from above downwards entirely
through the lateral loop and somewhat stretched so as to place the latter as high
up on the inverted end of the vessel as possible. The compression-forceps are
now to be removed and the vessel allowed to retract while the everted end is
to be carried to the bottom of the wound. When the operation is to be perform-
ed on an undivided vessel — this is to be laid bare and insulated as for the appli-
cation of a ligature, to about four times its diameter if a small one, and to about
three times if a large one. One of the compression forceps is now to be applied
at each end of the insulated portion, which is to be divided in the centre by a
sharp knife and both ends of the vessel beginning with that nearest the heart
are to be interlooped as in the case of a divided vessel.

The description of the operation, of which the above are the general outlines,
is followed by observations on the various circumstances occurring, either during
the operation or subsequently, by which it may be impeded, or its beneficial
results diminished or destroyed. It is not our intention here, to give an account
of them ; to those who would desire to make themselves familiar with the ope-
ration, a superficial notice of them would be of little or no value, and our limits
will not permit us to enter into minute details.

We may remark, however, that among the things to be guarded against in the
performance of the operation, the following are described as the most prominent.

Hemorrhage, from- the slipping off of the compression forceps from the end
of the vessel — this is to be avoided by care on the part of the operator; — when
it occurs, the divided end of the vessel must be sought for in the usual manner,
and the forceps again applied.

The longitudinal incisions, by which the loop on the side of the artery is
formed, may be made too long, or too far from the side of the vessel towards
the centre of its upper surface, or they may be made too near to the edge or too
short. In the first two cases the operation will be rendered unsuccessful — the
blood escaping through the incisions ; — in the third case, the loop will be liable
to be torn in carrying the end of the vessel through it, or become too much
stretched to retain the latter. In the last case, the end of the vessel cannot be
carried through the loop without difficulty or injury to the former. Where the
incision is too short, the difficulty may be obviated by enlarging it; but in the other
cases, the lower end of the vessel must be cut off, and the operation repeated
higher up.

The loop may be made too near to the divided extremity of the vessel, so that
the end of the artery is allowed to slip out of the loop. — The incision in this
case must be made on the opposite side of the artery, somewhat higher up.

In the contrary case, when the loop is made too high up, the vessel is too
much dragged forward, or laid bare to too great an extent, and cannot retract
sufficiently, but coming in contact with the soft parts at the bottom of the w^ound,
it is bathed in the matter produced by suppuration, which is especially to

^15

174

Bibliographical Notices,

be avoided. The best procedure in such case, is to remove a portion of the
end of the vessel by a sharp knife or scissors.

The perfect closure of the divided end of the vessel, after the loop operation,
takes place, it is stated, in about the same time as after the other operations for
arresting traumatic hemorrhage.

In the second of the works before us. Dr. Stilling has presented a very f’’^^
and interesting history of the natural process by which the divided p’
blood vessel is permanently closed, subsequent to the loop oper'^'
from an extensive series of experiments on animals. From /'
it appears, that the divided end of the vessel soon retracts to a greatei or .
degree in different cases, and at the same time lessens in diameter, and there
forms within the vessel, between the part at which the loop is formed and the
first lateral branch, a coagulum by which the entire obliteration of the vessel is
effected. The circumstances connected with this coagulum, denominated by
the author, the thrombus, and the gradual changes which it undergoes, constitute
the principal theme of the present work. The following are the general conclu-
sions deduced from the observations and experiments of Dr. S., on this subject.

In arteries, the formation of the thrombus commences soon after the closing
of the vessel, and is completed within the first eighteen hours.

The greater the repose of the blood at the closed end of the vessel, from
diminished action of the heart and of the voluntary muscles, the more rapidly the
thrombus forms, and vice-versa. Hence its formation commences later in the
end of the vessel towards the heart, than in the opposite one.

The greater the tendency of the blood to coagulate, the quicker the thrombus
is formed, and vice-versa. It is formed more early also, in the smaller than in
the larger vessels.

The thrombus, is formed by the coagulation with a greater or less separation
of its parts, of the blood contained in the closed end of the vessel below the first
considerable lateral branch. The colouring matter of this blood, the cruor, forms
always the basis and body of the thrombus, and in small vessels the extremity
also. The fibrinous portion collects especially towards the extremity of the
coagulum, which in the larger vessels is formed by it exclusively. When the
amount of fibrinous matter is small, and the disposition of the blood to coagulate
is consequently diminished, it does not become separated in the thrombus from
the cruor: when the fibrine of the blood is more considerable, and it is disposed
to coagulate rapidly, the thrombus is formed of layers of the red globules, and
of the fibrine.

The serum of the blood forming the thrombus is partly diffused throughout
the substance of the latter, partly imbibed by the parietes of the vessel, and
partly escapes through the lateral branches given off at the closed extremity.

The form of the thrombus in vessels either closed by ligature or by a loop,
is that of a spindle, or of two unequally sized pyramids connected at their bases
by a cylindrical portion, their points presenting in opposite directions. The
external surface is in general smooth. The apex of the smaller pyramid or cone
is directed towards the closed extremity of the vessel. The body of the throm-
bus is formed of a cylindrical portion, tapering in the direction of the heart,
which, according as it is longer or shorter, causes the cylindrical or pyramidal
form of the coagulum to predominate. In the generality of cases the longest
pyramid forms the apex of the thrombus — this, however, is often, only the
short truncated termination of the body of the coagulum : the greater the
amount of fibrine the blood contains, the more acuminated is the point, and vice
versa.

The apex is always directed towards the still pervious portion of the vessel,
— consequently towards the heart in the upper portion of the divided vessel,
and from it in the lower portion.

The length of the thrombus is always in proportion to the distance of the
orifice of the first considerable lateral branch from the closed extremity of the
vessel — the more remote this occurs the longer is the thrombus, and vice versa.

Small lateral branches which- go off near to the closed end of the vessel and
quickly ramify, are filled with a prolongation of the coagulum. In large arteries

175

Stilling’s New Process for arresting Hemorrhage.

a still pervious lateral branch is also often partly filled, by a prolongation from
the apex of the thrombus.

The diameter of the base, and of the body of the thrombus corresponds, in most
cases, with that of the calibre of the vessel, and, hence they fill completely
the latter, but at the apex the diameter of the thrombus is always less.

In the larger vessels the colour of the thrombus, at its base and body, is
dark red or black, towards the apex, it becomes gradually lighter, the apex
itself being whitish or yellowish. In smaller vessels the entire coagulum is
of a dark red colour. Internally, the colour of the thrombus differs from that
of the surface, only in those instances in which the fibrine predominates, more
or less, in the concentric layers of which the coagulum is composed.

The thrombus at first adheres but loosely at its basis to the parietes of the
vessel, and scarcely at all at any other part, its apex is always entirely
free : in cases, however, in which the inner coat of the vessel has been torn or
otherwise injured, a more extensive adhesion may early take place.

The thrombus is the least firm at its basis and body, more so towards
its apex, and at the latter the most.

The coagulum in its first period affords ho security of itself against the escape
of the blood from the extremity of the vessel.

According to the size of the artery in which the thrombus is situated, blood
vessels commence, between the first and sixth days, to be formed in the latter —
in small vessels the earliest and in large vessels the latest. They appear first
on the body and in the centre, and subsequently at the basis; when the forma-
tion of these vessels in thrombus takes place, a plastic substance is formed
within it as well as on its outer surface.

No change takes place in the form of the thrombus until towards the termina-
tion of this period, when it becomes diminished in every direction, and the outer
surface of the base and body to be covered with flocculi, while generally the
surface of the apex remains still smooth.

The colour of the thrombus becomes of a brighter red than in the first period,
first on its middle portion and at its apex — it gradually changes from a dark
flesh red to a pale rose colour.

The adhesion of the thrombus to the inner surface of the vessel at its basis,
and Commonly over a great portion of its body is now firm, so that it can be
separated only by force : usually the apex is still free.

The firmness or density of the thrombus becomes gradually alike throughout,
and may be compared to that of a firm flesh granulation.

The foregoing changes take place more rapidly and earlier in small vessels,
than in the larger, and also quicker in the divided end of the vessel farthest
from the heart, than in that nearest to it.

The thrombus, in the generality of cases, now forms a complete security
against any hemorrhage from the end of the vessel which it closes.

In the third period, the thrombus consists of a uniform homogeneous animal
matter, its form is similar to that of the portion of the vessel in which it is
formed — being cylindrical in most cases, but often however spindleshaped or
conical. Its colour is at first yellowish, subsequenly grayish, white, or entirely
white. Its consistency is that of a fibrous cellular mass. It now adheres
throughout to the inner surface of the artery; excepting, that, at first, a portion of
the apex corresponding with the calibre of the vessel, remains still free, but
this free portion is gradually diminished, and the cavity of the vessel is com-
pletely and firmly closed, presenting the shape of an imperforate funnel.

The length and thickness of the thrombus still gradually diminish, until at
length, the entire portion of the vessel which it occupied, to the first lateral
branch, is entirely absorbed — and the occurrence of any subsequent hemorrhage
is effectually guarded against.

In veins, a thrombus is never formed at the divided extremity next the heart,
and in the end farthest from the heart it forms later than in the arteries.

The whole of the changes which the thrombus undergoes, proceed more
quickly in veins, than in arteries — and in the smaller veins quicker than in the
larger.

170

Bibliographical Notices,

In veins, the thrombus contains more red globules and less fibrine than in
arteries — the apex never being purely fibrinous as in the latter.

In veins, during its first period, the thrombus possesses less firmness or
density than in arteries; — in other respects the circumstances of, and the changes
which take place in it, are alike in both sets of vessels.

The third publication of Dr. Stilling, the title of which is prefixed to the
present notice, contains an account of a successful amputation of the thigh, in
which the closure of the femoral artery, the deep seated artery of the thigh and.
the femoral vein was affected, by looping the ends of the artery in the manner
already described.

Xhe patient was a female ten years of age, who after an injury, caused by a
fall on the upper part of the left thigh, followed by inflammation and suppuration,
became affected with caries of the femoral bone. The limb was amputated
about a finger’s breadth below the great trochante?:. The stump healed entirely
by the first intention.

In a note appended to this work the author examines the opinion uttered by
Dr. Ungar, as the result of his experiments, upon the value, of the loop opera-
tion as a means of arresting hemorrhage, namely, that it is entirely useless —
and has endeavoured to show, that this opinion has been formed entirely from
the unskilful manner in which the operation was performed by that gentleman,
in his experiments upon animals.

The incisions through the sides of the artery forming the loop, were, he asserts,
too long, in consequence of their being measured by the diameter of the vessel
when distended with blood, no attention being paid likewise to the greater or
less thickness of the parietes of the vessel in measuring their diameter. The
forceps used in looping the divided end of the vessel, were in the opinion of Dr.
S. not adapted to its successful performance.

We have now presented to our readers, from the works of Dr. Stilling, placed
in our possession by the politeness of Dr. Stahl, of Vincennes, a tolerably full
account of his novel operation for arresting hemorrhage from divided vessels. —
No one can doubt its practicability, however much they may its superiority,
in the generality of cases, over the ligature and the other methods of securing
divided vessels now in use — of its real value we profess ourselves to be incom-
petent to form an opinion — this can be determined only from the result of ex-
perience ; though we are inclined to fear that the amount of skill required for
its successful performance — the time it will consume even in the most favour-
able cases, and the many readily occurring circumstances which are capable of
increasing its difficulty, of diminishing the certainty of its success, or of causing
it altogether to fail, will stand very much in the way of its general adoption.

D. F. C.

Art. XVII. — Recherches Medico-physiologiques sur V Eledridt'e Animate : Suivies
d' observations et de considerations pratiques sur le procede medical de la neutrali-
sation electrique directe, notamment appliquee au traitement de V Ophthalmie, de
V Erysipele de la Face, de la Cephalalgie, de la Migraine, des Derangemens de la
menstruation, des Affections rhumatismales, de quelques Affections nhvropathiques,
^c. Par J. F. CouDRET, M. D. P. &c., Paris, 1837. pp. 496. pi. III.

In this work Dr. Cohdret sets out with the following physiological maxims :
1. that the nerves are true organic conductors; 2. that electricity must be
considered as their active or moving principle; 3. that they present, like the
galvanic apparatus, two different and distinct kinds of currents ; 4. that one of
these currents, destined to the functions of sensation and intelligence, passes
from the internal and external senses to the brain ; the other, destined to the
functions of nutrition and locomotion, passes, on the contrary, from the brain or
the spinal marrow, to the differont parts of the muscular system and of the vast
apparatus of capillary vessels.

Couilret’s Researches on Animal Electricity. 177

The notion that electricity is the true nervous fluid is by no means new, and
we shall presume that our readers are familiar with the reasons which are
usually given in proof of it. But Dr. Coudret adds to this theory two proposi-
tions which are the foundations of his work and of his electro-medical practice.
They are, 1. that every part of the system suffering under pain or inflammation
disengages an appreciable excess of electricity ; 2. that any means suited to
withdraw or to neutralise this fluid will produce the most evident and salutary
antiphlogistic and sedative effects.

The apparatus made use of for experimenting on this subject is called the
Medical Electromotor, and is the invention of Mr. Fozembas of Bordeaux.
It consists of a glass box or cup, having a metallic base, to which are attached
a number of sharp metallic points, extending to within a short distance of the
open mouth of the cup. To the outer surface of the base, a metallic cord is
affixed. In using this apparatus, the cnp is attached by silk bandages, with its
open mouth over the inflamed part, which has thus a number of metallic points
brought near to it, though not touching it. The metallic cord is then made to com-
municate either with the surrounding conductors, such as the walls of the building,
so that electriciity may be conveyed through it to the earth — or it is attached to an
electroscope, if the object be to show that there is really electricity present.

The first object of the experiments related by the author is to establish the
fact of the presence of free electricity in an inflamed or painful part; and this he
asserts that he has done, in several cases, particularly of erysipelas and cepha-
lalgia ; and he states that the electricity was always negative or resinous.

The second and principal object is to show that pain and inflammation may be
relieved, and numerous diseases cured, by withdrawing or neutralising the
electric fluid thus generated in excess ; and in proof of this, the author relates,
in detail, no less than ninety-five cases treated by the Medical Electromotor.

We shall make but one or two remarks on this work. And first as to the
fundamental theory. Though we are not disposed either to assert or to deny
that the nervous action may be exercised through the agency of electricity, we
think it evident that, if this be the case, it must be electricity in its galvanic
form, and not in the state of tension of that excited by friction. For the latter,
the whole human body is a good conductor, and we cannot therefore conceive
how currents of such electricity could be carried separately along the nerves ;
or how an excess of it could remain accumulated in a painful or inflamed
part. Now the apparatus of M. Fozembas, armed as it is with points placed at
a distance, even though it be but a moderate one, from the inflamed surface,
would not collect from it electricity of such low tension as that which could be
insulated by a moist nervous sheath. We feel confident, therefore, that there
must be some fallacy in our author’s first experiments. He states, indeed, that
it was only under peculiar circumstances, and with the use of great precaution,
that he could succeed in showing the presence of electricity by Volta’s collector :
the individual must be young; the skin must be dry ; the air clear, &c. Now
what certainty have we, that, in the few cases in which the experiment was suc-
cessful, the electricity came from the nervous system at all 1 May it not have
been collected from the air, (which always contains it,) or may it not have been
excited on the dry skin by the glass cup or the silk bandages 1 It is worthy of
remark, that in three cases in which Professor Piorres made trial of the appa-
ratus on persons in full health, the electroscope gave the same indications as
where there was inflammation or pain.

As to the numerous cases of cure related in the work, we must acknowledge that
they, also, fail to carry conviction to our mind. When a peculiar system is to
be sustained, it is a lamentable truth that medical facts are no more to be relied
upon than mere medical speculations. If the hypothesis of Messrs. Fozembas
and Coudret be true, that electricity is accumulated in an inflamed or painful
part, and that its withdrawal will cure the complaint, the metallic tractors of
Perkins must have answered this purpose quite as effectually as the Medical
Electromotor, and he made his appeal to facts quite as triumphantly. It is a
very significant circumstance, as to both these instruments, that their advocates

178

Bibliographical jNotices.

avow, that, to make them effectual, the system must be prepared^ by bleeding,
diet, and other medical means. Thus, also, the empiric is always the most suc-
cessful with his nostrums after the regular physician has tried all his remedies.
The Tractor of Perkins has fallen into disuse and oblivion. Is it uncharitable
to predict the same fate for the Electromotor of Fozembas 1 R. M.. P.

Art. XVIII. — A Treatise on the Diseases of the Chest, and on Mediate Auscultation.
By R. T. H. Laennec, M. D., Regius Professor of Medicine in the College
of France, &c. &c. &c., translated from the third French edition with copious
notes, a sketch of the author’s life, and an extensive Bibliography of the dif-
ferent diseases. By John Forbes, M. D. F. R. S. &c. &c. To which are ad-
ded the notes of Professor Andral, contained in the fourth and latest French
edition, translated and accompanied with observations on cerebral Auscultation.
By John D. Fisher, M. D. Fellow of the Massachusetts Medical Society.
With plates. New York, Samuel S. & William Wood, 1838, pp. 784, PI. II.

The Treatise of Laennec on the diseases of the Chest has become an esta-
blished classic in medical literature. Its great merits known and acknow-
ledged, and to discuss them now might consequently be deemed presumptuous.
We may be permitted, however, to call attention to the present edition which is
the most complete extant. It is enriched by copious additions by Dr. Forbes,
Professor Andral and Dr. Fisher, and may be considered as embracing a com-
plete summary of our knowledge of the diseases of the thoracic organs. It
should be in the hands of every student.

Art. XIX. — A Lecture on Loxarthrus or Clubfoot. By Thomas D. Mutter,

M. D., Lecturer on Surgery; Fellow of the College of Physicians, &c. Phila-
delphia, 18'39. pp. 104. 8vo.

This is an exceedingly interesting lecture. The various forms of club-foot —
the pathological condition of the joints in each— the method of dividing the tendo
Achillis, in order to bring down the heel; and the various apparatus subsequently
required for the cure of the deformity, are fully set forth and exemplified by
figures. Appended is a report of twenty-eight cases treated by the author by
the methods he describes.

We are unable to give an analysis of this lecture, as it would not be perfectly
intelligible without figures, and we regret this the less as the work can be
readily obtained by those who are interested in the subject.

We must not, however, neglect to correct an oversight, in relation to the opera-
tion of our correspondent. Dr. James H. Dickson of New York. After award-
ing to him the merit of being the first to perform the operation of dividing the
tendo Achillis for the cure of club-foot in this country. Dr. Mutter observes,
“ Strange as it may seem, he has never, so far as I have been able to find,
reported his case or the means by which the, cure was attempted. A statement
was promised, some time since, but has not I believe made its appearance.”
Now, “strange as it may seem,” this statement was published in this Journal
for November, 1838. p. 96, the very succeeding number to that in which the
report was promised.

We may also state that loxarthrus is incorrectly used as synonymous with
club-foot; it is a generic term (from Xo^o? oblique and a joint) applied to all
obliquities of joints without dislocation — as wry neck, club-foot, &c.

The following is the author’s Resume of his cases :-^Of the 28 cases, 21 were
congenital, and 7 acquired.

Varus, 19, Valgus 2, Pes equinus 7. In males 19, in females 9. Both feet
were affected in 16, one only in 12. The right was deformed in 8, the left in 4.

Practical Surgery. 179

Two were in children between birth and the first year; 9 in children between
first and sixth year; 16 in persons between sixth and thirtieth year, and one
in a person between thirtieth and fiftieth year.

Twenty were perfectly cured and 8 are under treatment.

One was cured in from ten days to four weeks ; 9 were cured in from four
weeks to two months ; 10 were cured in from two to four months.

These results are highly creditable to the skill of the operator.

Art. XX. — Practical Surgery : with one hundred and thirty Engravings on Wood.

By Robert Liston, Surgeon. With notes and additional illustrations, by

George W. Norris, M. D., one of the surgeons to the Pennsylvania Hospi-
tal. Philadelphia, James Crissy, 1838, pp. 374, 8vo.

In a former number of this Journal (for May 1838, p. 160), the original edi-
tion of Mr. Liston’s Practical Surgery was noticed, and a very favourable
opinion expressed of its merits. As confirmatory of this judgment, we may
mention that within a year from its first appearance, a new edition was called
for in England. We cannot doubt but that its merits will secure for it nearly
equal success in this country.

The American edition is enriched by notices of the manner in which some of
the more common surgical affections are treated with us ; certain points lightly
passed over by tlie author are fully elucidated, and the details of several Ameri-
can operations, remarkable for their rarity or originality, are given. These addi-
tions are important, and are written in good taste. They evince on the part of
the editor, not only extensive and careful research, but also the possession of
sound surgical judgment.

The work should be in the hands of every young surgeon.

Art. XXL — Tenth Annual Report of the Inspectors of the Eastern Penitentiary of
Pennsylvania. Philadelphia, 1839. pp. 28, 8vo.

The portion of this document, more particularly interesting to our readers is,
the physicians’ report. The influence of confinement, especially solitary con-
finement, on the health of prisoners is now attracting great attention, and every
contribution, however small, calculated to aid in settling the vexed questions
relative to this subject, must be considered as valuable. We shall therefore pre-
sent a full abstract of Dr. Darrach’s report.

The number of prisoners received into the Eastern Penitentary during the year
1838, were 178, of which 115, were white, and 63 coloured.

Of the 115 white 68 were in good, and 47 in imperfect health.

Of the 63 coloured 30 were in good, and 33 in imperfect health.

The diseases under which the 80 prisoners laboured are given as follows: —
Syphilitic 39, thoracic 28, abdominal 15, febrile IG cephalic 6, various 17, ma-
king 116 diseases. Of course some! of the prisoners must have suffered from
complications; what these were is unfortunately not stated.

“The prisoners discharged this year,” Dr. Darrach observes, “ classed in re-
ference to health and colour, are —

1 White prisoners admitted and discharged in

good health, -

2 do do admitted and discharged

in imperfect health,

3 do do discharged in better

health than when received,
do do discharged in worse
health than when received,

1
67

ysi White.
5J

180

Bihlio graphical Notices.

1 Coloured prisoners admitted and discharged

in good health, - - - 22

2 do do admitted and discharg-

ed in imperfect health, - "z n i j

3 do do discharged in belter Coloured.

health than when admitted,

4 do do discharged in worse j

health than when admitted, - 2J
making of the 121 total dismissions, 91 in good, and 30 in imperfect health.
The diseases which these thirty discharged prisoners have taken with them into
the community, are 13 cases of dyspepsia, 4 of cough, 2 of palpitation of the
heart, 1 the effect of small pox, 1 of painful swelling of the inguinal glands, 1
of scrofula, 3 of thoracic pains, 1 of chronic catarrh, and 1 of rheumatism.

“ It is evident from the above statements, that the Penitentiary has received
from the community, a heavy amount of disease, and that it has discharged
very little. 55.5 per cent, only of the admissions were in good health, whilst
the dismissions in good health are as high as 75.20 per cent., a surplus of health
from this institution of 20.15 per cent.; again, 44.27 per cent, of the admissions
were in imperfect health, whilst the dismissions in imperfect health were only
24.70 per cent., a surplus of ill-health from the community of 19.48 per cent.,
that is, the Penitentiary has been the recipient of disease, and dispenser of
health.”

The small-pox appeared in the Institution, and out of 401 prisoners, 59 cases
occurred, 15 of which were unmodified, and the remainder of a more; or less
mitigated form of the disease. Two white men died of the disease, and three
coloured men from the sequelae.

“ The first case of small-pox occurred on the 29th of January, in a white pri-
soner, No. 395, aged 48 years, occupying a cell in the lower story of the 4th
block, and who had been in solitary confinement two and a half years. He had
been neither inoculated nor vaccinated, and suffered a severe, unmodified form
of the disease. At the time of the attack, he w'as employed in mending old
shoes brought from the House of Refuge, a pair of which had been worn by a
lad, shortly, or perhaps immediately before a very mild attack of varioloid.
Through inadvertence, the clothing of No. 395, were washed by a white male
prisoner. No. 824, on the 5th of February, who also was unvaccinated. On the
1st of March, he sickened, and after very severe and protracted suffering, re-
covered with the loss of an eye and with other mutilations. These, and other
cases, indicate a contagious and highly malignant character of the disease. It
observed, however, the ordinary laws of an epidemic, in the diversified locality
of the cases throughout the different blocks of cells, its common premonitory
symptoms and type, its gradual approach and termination, its long intervals,
and its sudden augmentation within a short centre period, nineteen cases only
occurring during forty days, then twenty-five in only five days, and then again
thirteen cases only in the last twenty-five days of jts existence.”

“ In regard to the effects of continued solitary imprisonment on the mind,” Dr.
Darrach states* “ two years’ observation inclines me to believe that the cases of
mental disorder occurring in this Penitentary, are, with a few exceptions, of
short duration, curable, and caused by masturbation, and are mostly among the
coloured prisoners. The facts contained in the following table, throws light on
this subject.”

Diseases in the Eastern Penitentiary.

181

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TABLE OF THE MENTAL DISORDERS IN THE EASTERN PENITENTIARY, DURING 1838.

182

Bibliographical Notice's,

“The terms, Mania, Monomania and Hallucination, used in this table, have a
fixed meaning; but Dementia is a term liable to discussion, owing to its more
or less copious, and its unsettled signification. It is used to designate those
varieties of weakened intellect which result from old age, palsy, and kindred
diseases; that which occasionally alternates with mania and melancholy, and
that in which these forms of insanity too often terminate. Dementia, is how-
ever also applied to those cases of weakened intellect, w'hich are produced from
masturbation, of which there are evidently two kinds; viz; 1st, that which E^-
quirol places under the second variety, of his third species of insanity, and is
called chronic dementia; 2d, that which is recent and may properly be placed
under the first variety, called by this distinguished authority on mental disor-
ders, acute dementia. The cases in the table, are mostly of this latter kind.
By masturbation, the physical energies of the cerebrum are diminished, whilst
those of the cerebellum are morbidly augmented, so that with the incoherence
which characterizes dementia, there exists also erroneous perceptions, and a
manifestation, more or less violent, of ungoverned and lustful passions. If,
through ignorance of this specified cause, and consequent inappropriate treat-
ment, these acute cases of dementia are permitted to continue, they become, I
apprehend, the sad cases of chronic dementia from masturbation, which are
found in Lunatic Asylums and Hospitals. The treatment in the Eastern Peni-
tentiary, has, as yet, prevented such results.

“ The important facts disclosed by the above table, are 1st, that the period of
continued separate imprisonment, previous to mental disorder, is very short; in
ten of the eighteen cases, it is less than a year, the longest being 8 months and
5 days, and the shortest only 39 days, making an average time of only 5 months
and 12 hours. The average time of the other eight cases, is about 2 years and
91 days. Four of these cases are coloured prisoners, who had only short at-
tacks of acute dementia from masturbation. Of the remaining four cases, No.
661 became first irritable, obstinate and violent from masturbation, then mono-
maniac, and after becoming fatally consumptive, recovered his mind. No. 342
had his attack immediately after the healing. of a chronic scrofulous running of
his ankle joint, and now he is at work, with a mild peculiarity of mind on cer-
tain subjects. No. 675 is an aged prisoner, who came in vexed about being
falsely imprisoned by false witness; after 4 months 18 days of mental debility
and hallucination, he is now comfortably at work. No. 546 had for 14 days an
hallucination of a pistol presented at his wicket constantly; he is now fat and
florid, and at work, but is obstinately of the opinion that the pistol was pre-
sented at him, and becomes excited if opposed in this belief. How can soli-
tude and confinement be the cause of these cases of disordered mind] If these
be tbe agency, it has been eflicient in ten cases in less than half a year. 2d.
Of 241 white prisoners, there are only 8 cases of mental disorder, equal to 3.33
per cent., whilst of the 161 coloured prisoners, there were 10 cases, equal to 6.21
percent., showing a double liability in the coloured prisoners of the Eastern
Penitentiary to disorders of the mind, which, I apprehend, is a novelty. 3d.
That the less intelligent of the prisoners, particularly the coloured, during the
early period of their imprisonment, practise excessive masturbation. I say
‘ the early period' because it is then this vice is chiefly practised, owing doubt-
less to their recent separation from all the low forms of sensuality, to which,
in the community, they were slaves, from which, however, they become gra-
dually weaned by the regular six days profitable labour, and sabbath rest, and
gospel ministry of their separate imprisonment. The effects of this practice,
are first to produce dyspepsia, then acute dementia, and finally chronic pleu-
risy and pulmonary tubercles. Remove this cause, and the diseases of this
Penitentiary will chiefly be those brought into the institution. I am happy
to state that my observations, during two years in this Penitentiary, have not
only exposed to me the chief causes of some particular diseases, but that
they have enabled me to apply more efficient treatment, and that in coming
years there is a prospect of less mortality, and fewer cases of mental disorder.
In view of the above facts, what effect has the solitude and confinement of

Diseases in the Eastern Penitentiary. 183

this Penitentiary, such as it is, with faithful, kind, supervision, daily labour,
well lighted, ventilated, and warm cells, and medical and gospel visitations
and ministrations, to disorder the mind of the prisoners. If such imprison-
ment produced this result, it has done it in the short average period of 5
months and 12 hours, in the cases of 10 prisoners this year, whilst hundreds
of prisoners, some of whom have been in its solitude and confinement for
years, have been already discharged from this institution in better state of
body and mind than when they entered it.”

The following tables show the mortality in tlie prison during the year, the
causes of death, &:;c.

WHITE PRISONERS.

Prison-

ers-

Diseases.

Causes.

State of ficaltlt on
Admission.

Length of Im.
at Decease.

No. 785

Ch. Inflam, of

Admitted with the

Bladder, &c.

Large Calculi encrysted.

Disease, . , .

Oy.

4m.

19d.

661

Consumption,

Masturbation

Good, ....

739

Consumption,

Syphilitic, ....

Secondary Syphilis,

42.9

Small Pox,

Unprotected, ....

Good,

887

Small Pox,

Unprotected, ...

Good, ....

304

Ch. Diarrhoea,

Ch. Dementia, from Mst.

Debility of body and

mind from Mst.

650

Consumption,

Tubercular Diathesis .

Frequent Haemoptysis.

COLOURED PRISONERS.

Prison-

ers.

Diseases.

Causes.

State of Health on
y\dmission.

L.ofim. at
Decease.

No. 615

Oonsmnption, - - . . . -

Ch. I’l. & Pericarditis

Ch. Pul. Disease.

ly 5m

347

iJhronic Inflammation of the Lungs -

Scrofula

Good health appar.

68^

Scrofula of the Chest

Syphilis

Sypnilitic

442

Chro. Inflam, of Stomach & Pleura -

Masturbation & Cold

251

Chro Inflam, of the Lungs - - - -

Do. do.

Good health

814

Do. do. do. . . - .

Chronic Pleurisy

Chro. Pul. Disease

67t

Do. do. do. . . . .

Do. do.

Good health

834

iJh. Inflam, of the Peritoneum - -

Small Pox and Scrof.

"■crofula

716

Ch. Itiflam. of the Bowels - - . -

Do. do.

Imperfect health

7()8

Consumption

Chronic Pleurisy

Scrofulous

44(i

Chro. Inflam of the Lungs - - -

Masturbation.

Good health

.574

Do. with Scrofula

Do. Syphilis & Scrof

Syphilis and Scrof

21)0

Do. do.

Double Chronic Pleu.

Good health app ly

645

Inflam. of the Bladder, with Paralysis

Vlst <k Ch. Pleurisy

Very good health

653

Ch. Scrof. Inflam. of Peritoneum &.

Scrof & double Chro.

knee joint.

Pleurisy

Scrofulous

815

Ch. Scrof. Inflam. of Peritoneum - -

Mst Si. double Ch. PI.

Imperfect health

546

Chro. Inflam. of the Lungs - - - .

Do. do. do.

Gonorrhoea

647

''onsumption - . .

Imperfect health

844

Consumption

Tubercles

Good health

1 1

“It appears from these tables of mortality,” observes Dr. Darrach, “that 26
deaths have occurred during the past year, a greater mortality by 44 per cent,
than has previously happened. This augmentation has evidently been owing to
small pox, chronic pleurisy and chronic tuberculous inflammation of the lungs,
among the coloured prisoners. These prisoners, of which there are 40.14 per
cent., have caused 73.07 per cent., of the mortality. The deaths directly and
indirectly caused by small pox, and the incidental case of stone in the bladder
being included, the total per centage of mortality among an average of 401 pri-
soners. is 6,t per cent., that among 241 w’hite prisoners is 2.86, and that among
161 coloured prisoners is 11.80; and exclusively of the 5 incidental cases, the
total per centage is 5.23 per cent., that of the white 1.65 per cent., and that of
the coloured prisoners 9.85. These estimates, in regard to the white prisoners,
show a mortality about the same as that in the community, whilst in regard to
the coloured prisoners, it is about double, as appears by the following table.

184

Bibliographical Notices,

Table of the Annual Mortality of White and Coloured Persons in the City and
County of Philadelphiay and in the Eastern Penitentiary of Pennsylvania,

Population.

White Pop. of City and County of Phila. 172,306
White Pris. of Eastern State Penitentiary, 241
Do. do. do.

Coloured Pop. of City and County of Phila. 15,655
Coloured Pris. of the Eastern Penitentiary, 161
Do. do. do.

Mortality.

Mortality in 1830, 3651

Entire Mort. in 1838, 7

Mort. without that
'from Small Pox, <fec. 4
Mortality in 1830, 643

Entire Mort. in 1838, 19
Mort. exclusive of effect
of Small Pox, &c. 17

Per Ct

2.11

2.86

1.65

4.10

11.80

9.85

“The important facts which this table discloses, are, 1. that the mortality among
the white prisoners of the Eastern Penitentiary, is only .75 per cent, greater than
that in the community; and that exclusively of the deaths from small pox, and
one from calculi, it is 46 less than that in it. 2. Among the coloured prisoners,
it is more than double of that of this portion of our city and county, With this
fact in view, it is not surprising that, among that depraved part of the coloured
population who become prisoners, there shall be an average of 9 per cent, of
mortality. This analysis will serve to correct an allegation which has been
made, that the mortality of the Eastern Penitentiary is greater than that of the
other prisons of the United States.”

We have restricted ourselves to giving an analysis of the interesting report of
Dr. Darrach, without indulging in any comments, but we must not, hence, be
supposed to adopt all the conclusions of its author. It seems to us, that many
more facts are required than those adduced in the report, to justify any positive
conclusions as to the precise influence of particular causes in the production of
the diseases of prisoners, and especially to authorise so general a reference of all
their diseases to a single vicious habit — masturbation. “ Remove this cause,”
observes Dr. Darrach, “ and the diseases of this penitentiary will chiefly be those
brought into the institution.” To detect the practice of this vice is usually
difficult ; to determine the extent that it is practised in our penitentiary would
require years of the most careful and closest observation ; and then it will require
no little investigation to determine how far it contributes, or is of itself operative
in the production of disordered intellect. Dr. Darrach’s position gives him
facilities, which we are sure he will not neglect, for the decision of these questions.

Art. XXII. — An Introductory Lecture to a Course of Lectures on the Theory and
Practice of Medicine^ in the University of Pennsylvania : Delivered at the opening
of the Session of 1838-39. By N. Chapman, M. D. Prof. &c., Phila. 1838.
pp. 19. 8vo.

This, like every production from the pen of the distinguished author, bears
evidence of classical reading, refined taste, and powers of eloquence. The
view which is presented of the scope and purposes of our profession is just and
liberal — one which must prove an incentive to the student to zeal and industry,
by showing him the responsibilities he will assume, and by leading him to a
proper estimate of the dignity and importance of our noble calling.

185

SUMMARY

OF THE

I M PROVE xM ENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

GENERAL ANA'IDMY AND PHYSIOLOGY.

1. Case of Natural Somnambulism. — The following case of natural somnambulism
is sufficiently interesting in itself to deserve notice, but it becomes doubly so,
when viewed in connection with the curious case of double consciousness, re-
corded in the original department of this No. (p.,49.) These two conditions,
seem to us, to belong to the same order of phenomena, as do also probably the
Mesmeric condition. It is only by carefully observing and comparing all
these states that we can ever hope to remove the thick veil by which for the
most part, the functions and pathological conditions of the nervous system are
now enveloped.

Madame Flambeau of Vancouleurs has, for about six years, exhibited the
most remarkable phenomena of natural somnambulism. She is 21 years of age,
of middle height, agreeable appearance and extreme timidity. She was married
at 17 years of age, and the year following had a daughter, who enjoys excellent
health.

The first act of somnambulism observed in Madame F. was when she was in
her 15th year. She was then at boarding-school, and learning music; notwith-
standing all her endeavours, she could not fix in her mind a certain romance and
its accompaniment; what was her astonishment one morning to find that she
knew both the words and the music perfectly! The preceding night she had
been observed by her schoolmates, to rise and dress herself, and she had spent
two hours in practising and repeating the song.

Dr. Verdet, the relator of this case, was first called to Madame F. on the
9th of August, 1836. She had suffered for some time previously to this period
from intolerable pain in the head^ of a somewhat remittent character. From
this she was relieved by loss of blood, and sulphate of quinine.

Dr. V. had then an opportunity of inquiring into the foundation of the rumours
afloat in the place, relative to this lady being subject to somnambulism. Her
husband who had endeavoured to conceal the circumstance, acknowledged its
truth to Dr. V.

The lady rose every night regularly between twelve and one o’clock, left her
chamber, walked out, returned, and conversed. Her husband, at first, paid little
attention to this; but having soon become convinced that his wife was a som-
nambulist, he took the necessary precautions to prevent her leaving her cham-
ber; and one night he shut and locked the chamber door, and, having hid the key,
he went to sleep in security. But at the usual hour, his wife rose, sought for
and found the key, opened the door, and went out as usual. In one of these
nocturnal excursions she took a pot of butter from the kitchen and concealed it
on the roof behind a chimney. The next day, and subsequently she complained

16*

186 Progress of the Medical Sciences.

of its having been stolen. Sometime afterwards she returned it to its former
place.

Some days after this, she put on during the night her ball dress, and perfectly
dressed and asleep, sallied forth at two o’clock in the morning, traversed a part
of the town, returned, and went to bed as if it were her usual time for retiring.

Another night she left her house about two o’clock in the morning,
walked through the streets in her chemise, and seated herself on a bench op-
posite to her dwelling. At this moment a carter passed with his vehicle, and
feeing her, took her for a ghost and struck her a severe blow with his whip.
The pain awakened her, and made her scream out, but she instantly relapsed
into her state of somnambulism, and returned home sobbing and went to bed to
her husband. The next day, there was a weal, painful, red and swollen, around
her body from one breast to the other, attesting to all but herself, the reality of
her apparition in the street. The cartman was distressed at his mistake.

Another night she went to the hospital at the same hour, and after having
rung loudly, she conversing with the sister of charity, who knew her situation,
and had opened the door for her, as if she were awake; afterwards having asked
for sister Regis to whom she was taken, she sat down, held a Idng conversation
with her, speaking very seriously, and, finally, allowed herself though reluc-
tantly to be led home.

One night she went in her chemise to the hospital and rung; whilst waiting
for admittance, she was seen by an opposite neighbour, who seeing her clothed
in white, took her for a ghost, and having crossed himself, endeavoured to drive
her away, by abusing her from a distance and threatening her. Surprised at
this unusual language, she became frightened and fled, disappearing like a
shadow, and leaving the exerciser persuaded that it was the spirit of a young
man who a few days previously had fled from the hospital.

Many nights she walked in her chemise in the burial place, to the great alarm
of credulous persons.

Finally, her nocturnal excursions becoming very frequent, and endangeringher
life, her husband was strongly urged to have a strict watch kept over his wife.
To prevent her walking out, her husband now adopted the expedient of locking
the chamber door, and taking possession of the key. The first night h« did
this, our somnambulist, after having in vain searched for the key, opened the
■w'indow, and jumped from a height of fifteen feet into the street. The shock
was violent, and occasioned severe pain in her head and right side. She awoke
for a few minutes, then relapsed into her state of somnambulism, entered her
house, and with difficulty got up stairs, and knocking at the door of her chamber
awakened her husband, who was not a little alarmed at seeing the window
open, and finding his wife at the door, with one foot bare, and the other with a
slipper on covered with mud. Three or four times afterwards, Madame F. not-
withstanding the precautions taken, jumped from the window in her sleep. In
consequence of these violent shocks, her health became impaired so seriously
that she was compelled to keep her bed.

She had a constant pain in the right side of her head; she was attacked many
times daily, and at irregular times, with such violent nervous paroxysms, that
three or four persons could not hold her. She was during this period, entirely
delirious. The hepatic region was renitent and very painful on pressure, pulse
frequent and full; face jaundiced; irregular, alternate chills and heat; and her
skin appeared alternately pale and red. Dr. Verdet was called to the patient,
and immediately bled her copiously, had her put into a bath, and ordered an
antispasmodic draught. The next day forty leeches were applied to the region
of the liver and this part afterwards covered with emollient cataplasms; the bath
was repeated. Subsequently, the pain in the right side of the head, being the
predominant symptom, leeches were applied to the angle of the jaw and behind
the ear of this side; and leeches were again applied to the region of the liver.
Notwithstanding this energetic treatment, the violence of the disease did not
decrease. So great was the sensibility of, and tumefaction of the hepatic region
that her physicians did not doubt but that suppuration was taking place there.

187

General Anatomy and Physiology.

Assafoetida was afterwards given in pills and in enemata, to calm the nervous
symptoms, but without any benefit.

One morning in visiting the patient, to her physician’s surprise, he found the
right hypochondrium soft, and not the least painful on pressure. The patient
stated that the previous night she had been attacked with a violent colic, had
two very copious and foetid stools, and from that moment, the pain had dis-
appeared.

From this period, the abdominal symptoms gradually ceased, but the nervous
phenomena continued. After a long and tedious convalescence, the treatment
during which is not given, the patient’s health is said to have become re-estab-
lished.

The patient, however, continues to be a somnambulist, but she does not endea-
vour to jump out of the window. She rises, lights a candle and the fire, tries to
get out, but finding the doors locked, she either goes to her spinning wheel, or
returns to bed. It is remarkable that she never rises more than once in any
one night.

The following is related as her last act of somnambulism. Her uncle, Abbe
T. was about giving a feast to the clergy. He desired the table to be laid the
night before, in order to prevent his servants being hurried the day of the feast.
This was neglected. Our somnambulist arose at midnight, and though she
was ignorant of where most of the articles were placed in her uncle’s closet,
she arranged the table in the most perfect manner; she did not even forget to
place before each guest, a common wine glass and a claret glass. She cut also
the bread, and placed a piece in each napkin. All this was done without
noise, without crowding, or breaking any thing; after completing the arrange-
ment she returned to her bed. The surprise was general.

The domestic who slept in the same room with Madame F. informed Dr. V.
that when the latter got up, and was interrogated as to her designs, she an-
swered tartly and almost angrily; she had her eyes open and fixed, and often
resorted to flattery to obtain what she desired. — Bulletin Gen, de Therap.

2. Observations on the Fluid of the Vesiculae Seminales of Man. — Dr. John
Davy, with the view of throwing light on the nature of the fluid of the vesiculae
seminales of man, there being still a difference of opinion among physiologists,
as to whether the fluid in question is secreted by the testes or vesiculas, has ex-
amined the fluid in the vesiculae, and in the vasa deferentia, after death, in a va-
riety of cases, in the General Military Hospital at Fort Pitt, and in a communica-
tion published \nX\\e Edinburgh Med. and Surg. Jour., for July last, he details the
results of twenty of these examinations, and the inferences deducible from
them. The latter are as follows ;

“ The first inference that appears to me unavoidable is, that the vesiculae are
seminal reservoirs, according to the old opinion on the subject, and that which
is still most commonly entertained by the continental physiologists. And next,
that they are not merely reservoirs, but are also secreting organs, furnishing
mucus, and perhaps some other fluid, for admixture with the semen.

“• The first inference is supported by the general resemblance, in several cases,
of the fluid of the vasa deferentia and of the vesiculae, and of the existence of the
characteristic spermatic animalcules in the fluid of the vesiculae, in every in-
stance in which they were detected in the fluid of the vasa deferentia.*

“The second inference is supported by there being a certain difference in almost
every case betv/een the fluid of the vesiculae and that of the vasa deferentia, and
especially by the circumstance, that the difference of quality is most percepti-

* I may add, that I have observed spermatic animalcules in the vesiculse of the
ram and bull, precisely similar to those found in their testes and vasa deferentia ; and
if I recollect rightly, they have been detected in the vesiculae of some other animals by
MM. Prevost and Dumas. Whether the vesiculae of certain animals, however, have
not a specific use, distinct from 4,hat of being merely reservoirs, appears to be deserv-
ing of further and special inquiry.

188

Progress of the Medical Sciences*

ble in the fluid of the fundus — where most out of the way of being readily mixed
with the fluid of the testes. What the exact difference of qualities is between
the fluid of the vesiculse and of the vasa deferentia, and, it may be added, of the
vasa deferentia and of the testes, in perfect health, remains to be ascertained. It
can be determined only by careful examination and comparison in the instances
of criminals who have been executed, or of persons who have been killed by
accident, not labouring under chronic disease, and in the vigour of life. I am
disposed to think that the difference will not be found very considerable, and
that between the fluid of the vesiculae and of the vasa deferentia^ it will consist
chiefly in the former being more dilute and perhaps more bland and mucous.”

“ Relative to the effects of disease on the fluid of the vesiculae seminales, and
on the spermatic fluid generally, the instances brought forward are too few to
admit of extensive induction. They seem to show, 1st, That chronic wasting
diseases, terminating in death, arrest the secretion of the testes, or the produc-
tion of those animalcules, on which, there is much reason to infer, the active
power of the semen depends ; 2dly, That the contents of the vesiculaj and vasa
deferentia, under the influence of disease, retain longer their characteristic qual-
ities than the Contents of the tubuli; and, Zdly, That there is least fluid in the
vesiculae and in the vasa deferentia, and that it is most altered in instances of
chronic diseases of the abdominal viscera, and especially of the intestines.

“ Admitting that spermatic animalcules are characteristic of and essential to
healthy spermatic fluid, in certain doubtful criminal cases, probably, decisive
evidence may be obtained by means of microscopical examination. The sper-
matic fluid undergoes change rapidly when exposed to the air, and even soon
becomes putrid ; but the spermatic animalcules, I find, resist change in a remark-
able manner. In one instance, distinct remains of these animalcules were
observed in putrid fluid, which had been kept ten weeks, at a temperature vary-
ing between 50*^ and 60° of Fahrenheit. In another instance, some fluid of the
vesiculae was applied to linen, and wrapped in paper and put by in a close
drawer. It was examined the following day; at the end of a week, and after
eighteen days, and each time animalcules were discovered under the microscope.
The mode of making the trial was by saturating a small portion of the smeared
linen with a few drops of water, and gently pressing out a drop for the experi-
ment. Fragments of the animalcules were very distinct, and sufficiently char-
acteristic ; and on careful inspection, an entire animalcule, here and there, was
observed. The application of these facts to the purposes of evidence does not
require any comment.”

3. On the Veins of the Uterine Decidua. — Dr. Robert Lee says that he has ex-
amined many ova which have been expelled from the uterus in the third month of
pregnancy, and in all of them he has observed the openings in the decidua re-
flexa, described by Dr. VVm. Hunter, near the angle where it joins the uterine
decidua. Those openings, he says, are of an oval shape, with smooth margins,
and they always pass obliquely through the membrane. If a blow-pipe be in*
sorted into one of these, the interstices of the villi of the chorion and placenta
are all readily inflated, and the air soon begins to escape freely from all the other
apertures in the decidua reflexa, around that opening into which the blow-pipe
had been inserted. If a tube with mercury be introduced into one of these ap-
ertures in the decidua reflexa, all the interstices of the villi of the chorion and
placenta are likewise readily filled, and the mercury afterwards begins to escape
from the numerous openings on the surface of the decidua reflexa. The same
thing happens if air or mercury be first made to enter the interstices of the pla-
centa, or villosities of the chorion. These circumstances render it probable that
by means of the apertures, in the decidua reflexa, which resemble venous canals,
there exists a free communication between the interstices of the chorion, and the
cavity formed between the decidua vera and reflexa, and that the maternal blood
circulates through these. This is rendered still more probable from the fact,
that in the greater number of ova, blood in a coagulated and fluid state is found
in the interstices of the villi of the chorion, and that by slight pressure the blood

189

General Anatomy and Physiology*

flows readily through the smooth openings in the surface of the decidua reflexa.
More or less blood is also found in all cases in the cavity of the deciduous mem-
branes, where these have not been lacerated in the process of expulsion. This
fact was pointed out by Breschet and Velpeau many years ago.

The inner surface of that portion of the uterine decidua corresponding with
the decidua reflexa is smooth, and is also perforated with a great number of
small, oval-shaped apertures. These openings in the uterine decidua arc found
to communicate with smooth canals, which run obliquely in the membrane to-
wards the uterine surface, and there terminate in larger openings, of an oval
form, with thin valvular-like edges. These canals in the uterine decidua have
other smaller canals opening into them as they proceed enlarging, towards their
termination on the uterine surface. Air or mercury passes readily from the inner
to the outer surface, along these canals, in the uterine decidua.

In many of the ova which I have examined, I have observed the little bags
described by Dr. Montgomery, on the outer surface of the decidua vera. On
opening these bags, their inner surface is almost always smooth, resembling the
inner surface of the uterine decidua, and in several specimens I have observed
at the bottom of these sacs, a small smooth aperture communicating with the
oblique canals above described in the decidua. Air or mercury introduced
into these bags, has passed freely into the canals, and escaped through the open-
ings on the inner surface of the decidua. If a blow-pipe be introduced into one
of the apertures on the smooth inner surface of the decidua, the oblique canals in
the membrane can all be readily inflated, and the air escapes on the uterine side
through the openings in the bags, and through other openings in the membrane. In
one instance, w'hat seemed to be a small coagulum of blood filled one of these sacs..

The following is the interesting description which Dr. Montgomery has given
of these cup-like elevations in the uterine decidua, and w'hich I am disposed to
regard as the terminations of those dilated decidual veins which convey the
maternal blood from the cavity formed between the deciduae, into the veins of
the uterus: —

“ Repeated examinations have shown me that there are, on the external sur-
face of the decidua vera, a great number of small cup-like elevations, having
the appearance of little bags, the bottoms of w'hich are attached to or imbedded
in Its substance; they then expand or belly out a little, and again grow smaller
towards their outer or uterine end, which, in by far the greater number of them,
is an open mouth when separated from the uterus; how it may be while they
are adherent, I cannot at present say. Some of them which I have found more
deeply imbedded in the decidua, were completely closed sacs. Their form is
circular, or very nearly so; they vary in diameter, from a twelfth to a sixth of
an inch, and project about the twelfth of an inch from the surface of the deci-
dua. Altogether, they give one the idea of miniature representations of the
suckers of the cuttle-fish. They are not confined to any one part of the surface
of the decidua, but I think I have generally found them most numerous and dis-
tinct on those parts of it which were not connected with the capillary rudiments
of the placenta, and at the period of gestation which precedes the formation of
the latter as a distinct organ; they are best seen about the second or third month,
and are not to be found at the advanced periods of gestation.”

Dr. Montgomery has added the following note to these observations: — “I con-
fess I am not prepared (nor, indeed, is this the place) to offer any very decided
opinions as to the precise nature or use df these decidual cotyledons, for to that
name their form, as well as their situation, appears strictly to entitle them; but
from having on more than one occasion observed within their cavity a milky or
chylous fluid, I am disposed to consider them reservoirs for nutrient fluids sepa-
rated from the maternal blood, to be thence absorbed for the development of the
ovum. This view seems strengthened when we consider that at the early
periods of gestation the ovum derives all its support by imbibition, through the

190 Progress of the Medical Sciences,

connection existing between the decidua and the villous processes covering the
outer surface of the chorion.^’*

If the preceding account of the decidual veins be correct, it appears that the
circulation in the human ovum in the third month of gestation is carried on in
the following manner: — The maternal blood is Conveyed by the arteries of the
uterine decidua into the interstices of the placenta and villi of the chorion.
The blood which has circulated in the placenta is returned into the veins of the
uterus by the oblique openings in the decidua covering the placenta. The blood
which has circulated between the villosities of the chorion passes through
the openings in the decidua reflexa into the cavity between the two deciduous
membranes, from whence it is taken up by the numerous apertures and canals
above described in the uterine decidua, and so passes into the veins of the
uterus. — London Medical Gazette, Dec. 1838.

4. On the Venous Circle of the Mammary Jlreola. — In dissecting the mammse.
Professor Sebastian had frequently observed a filament beneath the areola,
apparently describing a circle round it ; but being unable to procure the gland
of a. woman giving suck, he for a long while deferred the investigation of its
nature. However, by boiling an empty mamms for twenty-four hours, the
close cellular tissue of the organ was so effectually loosened, that an excellent
substitute for the full gland was obtained. By examining it he satisfied himself
that underneath the skin of the female areola a circle exists, which usually sur-
rounds the greatest part of the base of the nipple at the distance of a line and a
half from it. In some cases instead of being circular it is angular, its angles
giving origin to branches running towards the circumference of the areola ; other
smaller twigs ascend from it into the nipple itself. Its vascular and venous
nature was proved by injection. The circle exists in the male also, though in
him it exhibits a somewhat different form. This anatomical fact has altogether
escaped the notice of modern observers, at least no mention is made of it by
Meckel, Cloquet, Weber, Lenhossek, &c. The indefatigable Haller, however,
distinctly described it in his Elements of Physiology, vol. vii. sect. 1. Sebas-
tian proposes in consequence that it be called Haller’s circle. As to its use, he
believes that it has much to do with the erection of the nipple. Hitherto that
part of the breast has been referred to the class of erectile tissues, more on account
of its exhibiting the phenomenon of erection, than from anatomical demonstra-
tion of its structure. But when the venous circle becomes turgid from being
filled with blood, and at the same time the veinules forming communications
between it and the nipple are filled, the whole apparatus must push up and
cause the erection of the nipple.” — B. ^ F. Med. liev. Jan. 1839, from Tydsch,
voor Natuurl. Gesch. 1 1 Deel, 3 S.

5. On the accessory Supra-Henal Capsules. — By Professor Sebastian. — “In
the body of a woman who died of general dropsy, with tubercular disorganization
of the kidney, I discovered, attached to one of the supra-renal capsules, corpus-
cula of a different shape from that of the capsule itself, not more than a line and
a half broad, but of the same colour and structure as that organ. There were
evident fibres in the cortical substance and internally a distinct cavity. These
characters justify me in considering the bodies described as supernumerary
capsules. They could scarcely be looked on as lobes of the principal gland, as
they were only united to it by loose cellular membrane. I never felt persuaded
of the close relation of the supra-renal capsules to the lymphatic, but have
always felt inclined to refer its function to the vascular system. To me the vein
issuing from it appears to fill the office of an excretory duct, and to convey
either a material secreted from the arterial blood, or that fluid itself modified in
its properties, and destined for the improvement of the venous blood. The
great size of the organs in the foetus is thus accounted for, as also the peculiar

* An Exposition of the Signs and Symptoms of Pregnancy. By W. F. Montgo-
mery, M. D. London, 1837. P, 134.

Pathological Jlnatomy and General Pathology. 191

disposition of the vein itself, which is such that by it the whole gland is easily
distended. Thus too is explained the fact, that in diseases of the venous system
these glands are not unfrequently found either increased in bulk or otherwise
unliealthy. According to this view, therefore, the capsules would act the part
of a placenta. I have not discovered any distinction between the globules of
the supra-renal and renal veins. — Ibid.

PATHOLOGICAL ANATOMY AND GENERAL PATHOLOGY.

6. Exostosis of the Pelvis of unusually rapid growth. — The following example
of this was related by Wm. Lawrence, Esq., the distinguished surgeon of St.
Bartholomew’s Hospital, in a recent clinical lecture.

Mary Petit, thirty years of age, has gained her livelihood by selling fruit in
the streets, and has led an intemperate life. About six weeks before she came
to the Hospital she observed that the veins of the right leg were swollen, and
she attributed the circumstance to over exertion. Soon after, a tumour, the size
of a nut appeared in the situation of the femoral absorbent glands on the same
side ; it did not prevent her from following her occupation. As the swelling
increased, and became painful, especially on exertion, she applied at the hospi-
tal, and was admitted on December 21, 1837. At this time the veins of the right
lower extremity were varicose in a slight degree, and there was a tumour in the
bend of the thigh not larger than a pullet’s egg. Being of oval figure, with
slight irregularities of surface, it was considered to be an enlargement of the
femoral glands. It was free from redness, and not painful on pressure ; yet the
patient complained of considerable uneasiness in the part.

The Ung. Potassae Hydriodatis to be rubbed on the swelling.

29/A. — Great pain in the swelling.

Ten leeches ; linseed poultice.

Jan. Is/, 1838. — The tumour is larger, and so painful as to prevent rest at
night. The limb is cedematous.

Four grains of Potassae Hydriod. in two ounces of Decoct. Sarsap. Co. three
times daily. One-third of a grain of Muriate of Morphine every night.

9th. — The limb more swelled, with increase of pain.

The dose of Morph. Mur. increased to half a grain. An ointment, consist-
ing of Cerat. Cetac. ^ss., with Pulv. Opii, ^j. to be rubbed on the swelling in
in the thigh night and morning.

The tumour increased rapidly, and became more and more painful. Having
been at first movable like a glandular swelling, it became fixed, and extended
along the inside of the thigh, in the direction of the pubes and ischium, forming
a large mass, of firm feel, not painful on pressure, filling up the space between
the pelvis and the thigh. In the early part of April, the growth was found to
extend behind the abdominal muscles, towards the cavity of the pelvis. It con-
tinued to increase rapidly, both on the outside and inside of that cavity, its
growth being attended with correspondent general swelling of the limb.

On May 1st, the tumour, which is hard and incompressible, has stretched
across the pelvis to the left side of the body ; and the left leg begins to swell.
On May 17th, it had nearly reached the umbilicus. Her sufferings were con-
stant and acute, and only imperfectly relieved by opiates ; her strength was thus
exhausted, and dyspnoea came on in June, when she was so reduced and en-
feebled, that death was expected daily. She lingered till .luly 1st.

Neither local nor general means had the slightest effect on the complaint.
The treatment consisted in the free use of opiates, particularly of the muriate of
morphine, and in the allowance of such nutritious diet and cordials, including
animal food, sago, porter, and wine, as the weakness required, and the appetite
would admit of.

The disease consisted of an enormous mass growing from both sides of the
pubes and ischium, extending downwards to the groin and inside of the thighs

192

Progress of the Medical Sciences,

upwards to the pelvis and abdomen. The viscera were necessarily displaced,
the bladder and internal organs of generation being pushed towards the left side ;
while the abdominal contents were thrust upwards against the diaphragm. The
basis and centre of the mass were firm bone, and the growth at its origin Avas
identified with the bond from which it proceeded. The exterior was of softer
composition, and displayed a fibrous texture, more or less firm. On the surface
this exhibited, in some situations, cells containing either serous fluid or grumous
blood.

No disease was observed in the absorbent glands.

The thoracic viscera were healthy.

In its origin, and in the composition of its basis and interior, this tumour was
an exostosis ; in the rapidity of its growth, in the severe pain which accompanied
it, and in the constitution of its exterior, the characters were those of a malignant
growth. I have seen a somewhat similar combination of bony excrescence, with
softer growth, the latter being in some parts nearly medullary consistence, and
formed into cells containing bloody fluid, in the tibia, where, however, the
disease was of long standing. Thd limb was amputated, and there was no re-
production of disease. Had the disease been seated in the tibia in the present
instance, it would have been right to amputate. — Lond. Med. Gaz. Feb. 1839.

7. Hepatic Abscess opening into the Stomach by three perforations ; also into the
Pericardium. — By R. J. Graves, M. D. “The following case contains many
particulars of extreme interest, among which I beg to direct the reader’s atten-
tion more especially to the physical phenomena produced by the simultaneous
presence of air and fluid in the pericardial sac, no instance having been hitherto
recorded where similar symptoms, arising from ulceration extended to that sac,
have been observed.

“ In order not to lengthen the case too much, I have omitted the details ot
treatment ; they consisted of local depletion in the first instance by means of
leeches, and an attempt to mercurialize the system, which attempt failed, because
suppuration was in all probability established before it was made. My expe-
rience confirms the assertion made by Annesley and other writers on diseases of
tropical climates, that it is impossible, or at least very difficult, to make the
mouth sore to salivation, once the formation of abscess in the liver commences.
Of course no practitioner who is aware that hepatic suppuration has actually set
in will continue the exhibition of mercury; it tlien becomes injurious. In the
following case, when suppuration was ascertained, poultices were applied, and
various astringents were subsequently employed, in vain, to check the diarrhoea.

“Anne Walker, setat. 25, spinster, of spare habitand nervous temperament, on
Thursday night, 13th Sept., without any assignable cause, was seized with a
sudden and violent pain in every part of the abdomen, extending to the loins and
back, unpreceded and unaccompanied by any other complaint; was immediately
bled, but without much relief ; continuing in the same state, venesection was
repeated the next morning with more effect ; hot stupes were also applied. The
entire of the 14th (yesterday) she remained in excruciating agony, applying the
stupes, and obtained but little ease. She now lies on the back, with the legs
drawn up towards the body, unable to turn to either side, or stir in the least in
the bed, without an insupportable increase in her complaints : the pains she
describes as of a lancinating nature, sometimes resembling the pricking of ,a
number of pins, commencing at the epigastrium, shooting downwards to the
pubes, and extending laterally into each hypochondriac and lumbar region.

“ Since the commencement of the attack she has been deprived of sleep ; much
annoyed with constant thirst, and a nauseous, disagreeable taste in the mouth.
Her countenance is now anxious and distressed ; skin moist, and covered with
slight perspiration ; tongue white and moist ; pulse 128, small and somewhat
wiry; respiration 54; no morbid phenomenon can be detected in the chest;
heart’s action rapid, and sounds natural; the abdomen is tense, hard, and
exquisitely painful, the slightest degree of pressure causing much uneasiness ;
bowels free ; urine passed in regular quantities.

Pathological Anatomy and General Pathology. 193

“ In the rig-ht hypochondriam and epigastrium there is a considerable tume-
faction, somewhat of a conical shape, affording, when pressed, a degree of
elasticity and dulness on percussion; the pain produced in this part by pressure
is very acute, whilst elsewhere it is comparatively slight.

“ 19i^A.— The only part of the abdomen pained by pressure is that where the
tumefaction was observed yesterday ; it extends from below the ensiform carti-
lage to within a couple of inches of the umbilicus, also laterally, occupying a
space between three and four inches ; and to-day a sensation of fluctuation is
communicated to the touch.

“ 20/A. — A violent purging commenced yesterday, and continued the entire
night ; stools numerous, eight or ten, liquid, and of a dark colour, each being
attended with griping and kneading; was much troubled with shiverings and
pains in the back; her breathing is more distressed, and accelerated, 44 in the
minute ; pulse 132, small and hard ; tongue moist. No change has taken place
in the appearances of the abdomen.

“ 24^A. — There has been no return of the purging since the 21st ; the perspira-
tions are diminished, and her general aspect is improved; she now complains
principally of pains in the back, continued and shooting upwards along the
entire of the spinal column. When the tumour is now percussed, it emits a
tympanitic resonance ; the lower part of the left side also is very clear on per-
cussion ; cannot now detect the fluctuation observable on the 19th ; the elasticit}’^
remains as before; pulse 116, soft and improved in strength ; respiration 30.

“ 29/A. — The tumour in epigastrium is considerably diminished in size, per-
cussion elicits, as before, a tympanitic resonance, but does not extend, as on
previous days, to the right hypochondrium ; her countenance is improved, and
spirits not so depressed; breathing continues too free, and pulse rapid.

“ 0-zt. Is^.— Purging has returned, with griping pains in the abdomen, and
numerous liquid stools.

“ 2c?. Purging remains unchecked ; the tumour in abdomen has altogether
disappeared ; no tympanitic resonance is now afforded by percussion.

“ 6?A. — Heart’s sounds natural. Percussion and respiration over both lungs
as in the healthy state : abdomen sunken and free from pain.

“ — Bowels have been opened seven times within the last twelve hours.

Pulse 120. Respiration 30.

“9?A. — Was attacked yesterday with acute pain in the cardiac region, and
last night had a violent beating of the heart, also a burning heat below the left
breast. She cannot recollect any cause to which she might attribute this. Her
present state is extreme emaciation and debility, cheeks hollow, eyes sunken,
countenance dejected, and spirits languid; her breathing remains accelerated,
short, and distressed ; the jugular veins in the recumbent posture turgid, but
without pulsation ; likewise those along the trachea.

“ Percussion over chest generally is clear, except at the inferior and middle
portions of the left side. Respiration in these parts is feeble, elsewhere pure
and loud ; impulse of heart perceptible, but feeble. About half an inch distant
from the lower edge of the mamma both sounds are confused, and a slight
de souffiet is audible; advancing to the right it increases in roughness, and
below the mamma it becomes a complete creaking noise, accompanying both
sounds of the heart, and is still louder between the sternum and breast; when
pressure is applied it gradually increases these phenomena, and when conside-
rable pressure is used, they are changed into a \o\idi frottement, obscuring both
sounds, the first especially ; they are also rendered more distinct by holding the
breath.

“Abdomen smaller; purging stopped; pulse 130, small and compressible.

“ 10?A. — ^The phenomena are now nudible as far as the middle of the sternum,
over the cardiac region, and laterally, being in each place of the same character.
The sound is between bruit de souffiet and bruit de scie, in a great measure
masking the first sound and accompanying the second, which still retains its
clearness. Immediately under the mamma, together with these sounds, but
No. XLVII.— May, 1839. 17

194

Progress of the Medical Sciences,

heard only occasionally, is a peculiar metallic click, affording the idea of some
fluid dropping in or about the pericardium; it is removed when pressure is
made over the heart, whilst the other noises undergo a thorough change ; thirst
urgent.

“ — ^The irregular click, audible yesterday only at intervals, has now

become a loud metallic ticking, audible at each stroke of the heart over those
parts where the emphysematous crackling and other sounds were to be heard ;
it obscures all the phenomena hitherto noted, except a slight hruit de souffiet
about the nipple of the left mamma. Impulse cannot be felt. Is sinking fast.

“ \Zth, — Died last night at 10 o’clock.

“ Autopsy twelve hours after death. — Percussion over the front of chest afforded
no evident dulness ; over the cardiac region it was clear. When the sternum
was raised, both lungs were found collapsed ; the left in particular, which was
found compressed by a quart of sero-purulent fluid. Weak adhesions connected
both lungs with the external pericardium ; and their inferior lobes with the
upper surface of the diaphragm. The pericardium appeared enlarged, and a
small quantity of fluid could be felt.

“The abdominal parietes being removed, the cavity of a large abscess was
exposed, situated in the left lobe of the liver. Its form was circular, about
eight inches in circumference, and bounded anteriorly by a portion of the parietes
of the abdomen and ensiform cartilage. Its posterior wall was formed by the
remaining solid part of the left lobe ; whilst the diaphragm superiorly was in
immediate connection with it, and the falciform ligament served as a means of
separation between it and the right lobe : its thin edge was over-lapped by a
portion of the stomach ; and near the pyloric orifice was an ulcerated circular
hole, with rounded and smooth edges, about three-quarters of an inch in diameter,
communicating directly with the abscess. The stomach was intimately con-
nected with the sub-surface of the left lobe by its concave margin ; and near to
its cardiac extremity were two other openings, one somewhat oval in shape,
about half an inch in diameter, and connected with the abscess by means of a
canal capable of admitting the tip of the little finger, and separated from the
other by a thick band, evidently a portion of the stomach. This last perfora-
tion, or the one nearest the oesophageal extremity of the stomach, had no com-
munication with the abscess. The surface of the abscess is irregular, presenting
many depressions and elevations ; its colour of a yellowish gray, its substance
creamy, soft, and reduced by pressure into a pus4ike fluid ; when cut into, it is
at least three quarters of an inch in depth, but does not retain the same thickness
in every part; beneath, the structure of the liver is visible, and in firm connec-
tion with it the stratum of diseased substance, neither can it be separated
from it.

“ Where the diaphragm and pericardium are united, is a perforation sufficiently
large to admit the middle or ring finger, and opening directly from the abscess
into the pericardium ; the edges are ulcerated and uneven ; and within the cov-
ering of the heart are about two ounces of yellow coloured fluid mixed with
flakes of lymph. The pericardial sac is increased to four times its natural
thickness, but appears equally dense in all parts; its external surface is highly
vascular ; its interior is likewise inflamed, dotted with numerous red spots, in
some parts about the size of a pin’s head, and in others forming an arborescent
appearance ; the surface has in a great measure lost its natural glistening appear-
ance, and looks uneven, being coated in parts "With small portions of organized
lymph ; and generally, particularly towards the origins of the great vessels,
with small, granular, semi-transparent bodies, resembling millet seeds, or the
eruption sometimes seen in cases of rheumatic fever: its feel is quite gritty,
but when these bodies are scraped off, the serous lining of the pericardia is
apparent underneath.

“The heart itself is of a light red colour, and its investing membrane is cov-
ered, like the pericardial sac, with those granular substances more abundant
about the auricles and base of the heart. Both auricles are bound down to the

Materia Medica and General Therapeutics. 195

substance of the heart, by means of strong, tough, and organized pieces of
lymph.

“Some tubercles scattered through the superior lobe of each lung. No adhe-
sions existed between the peritoneum and intestines, or between these latter.

“ I am indebted to my talented and indefatigable clinical clerk, Mr. Thomas
Moore for the preceding report of the progress of this singular case, concerning
which the following remarks appear necessary : —

“ 1st. When the abscess burst into the stomach, the epigastric tumour which
the abscess formed did not at once subside, but suddenly, from having yielded
a dull sound on percussion, became tympanitic and clear ; air from the stomach
having found its way into the cavity, while the pus escaped.

“ 2dly. The now tympanitic tumour seemed so exactly to resemble the sto-
mach distended with air, that we were induced to pass a tube into the stomach,
but it did not give vent to any air.

“ 3rdly. In a few days the air also passed from the cavity of the sac ; then
all traces of the tumour entirely and unaccountably disappeared.

“ 4thly. The diarrhoea was caused by the perpetual flow of foetid and irritat-
ing matter from the abscess into the intestinal cavity.

“5thly. No peculiar symptom, pain, or derangement of its functions, denoted
the extensive ulceration of the stomach.

“ 6thly. The inflammation spread by continuity of structure, from the abscess
to the pleurh and pericardium in the first instance.

“ 7thly. Soon after the paricarditis thus formed had commenced, and at the
time that its usual physical phenomena were clearly perceived, a new' set of
physical phenomena arose, dating from the moment the pericardium was perfo-
rated, and air entered its sac.

“8thly. Although symptoms of most intense peritonitis existed when the
patient was admitted, yet no traces of general peritoneal inflammation were dis-
covered on dissection.

“ 9thly. It may be asked, why I had not recourse to an operation to let out
the matter, as soon as fluctuation had become plainly perceptible in the hepatic
tumour I My answer is, that the tumour formed so quickly, and seemed to tend
to the surface so rapidly, that I thought it better to wait for a day or two, in
order to render the operation safer, never anticipating that the matter could, in
so short a time, find an exit by another channel.”

8. Silver Spoon swallowed^ afterwards discharged through an abscess in the epi~
gastrium.—A man in a fit of insanity swallowed a silver teaspoon. Nearly a
year afterwards, an abscess formed in the epigastrium, and through this the
spoon was discharged. The wound healed perfectly. Rev. Med., March 1838,
and Zeitschrift fur die gesam. Med.

MATERIA MEDICA AND GENERAL THERAPEUTICS.

9. Kermes Mineral as an emetic and purgative. — The Gazette Medicate de
Paris Nov. IT, 1838, contains an account by Dr. Toulmouche of Rennes, of
some clinical experiments instituted for determining the emetic and purgative
powers of the Kermes mineral. The conclusions of Dr. T. from his numerous
experiments are 1. that the Kermes acts with more certainty as an emetic in the
dose of from two to three s’rains than in that of four or five; 2. that it more fre-
quently purges than vomits; 3. that its emetic action is uncertain, occurring in
rather less than half the cases; and finally, that it may be given with impunity
except in acute rheumatism, and pneumonia in very large doses; and that
its emetic and purgative action seems to diminish with the increase of the
dose.

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Progress of the Medical Sciences.

10. Method of determining the genuineness of Ergot. — Mr. T. H. Wardle-
woRTH states that his experience leads him to consider the following appearan-
ces as indicative of the genuineness of Ergot. — If some of this substance in
powder be put into a small vessel, (a cup for instance,) and about one ounce of
boiling water be poured upon it, the vessel immediately covered and kept so
for some seconds, the Ergot should remain totally insoluble, and the infusion
should assume a deep pink colour. On the contrary if small portions of the
Ergot be seen floating on the surface of the water, and the infusion presents a
milky appearance, then the action of the remedy cannot be depended on. Mr.
W. has never known it, when given under such circumstances, to produce the
least increase of uterine action, but invariably to be followed by more or less
of a feeling of sinking at the pit of the stomach attended with irregularity of the
heart’s action and total cessation of pain. — iance^, Noy. 10th, 1838.

11. Medical Properties of 7Anc. — By G. G. Sigmond M.D. Zinc and its che-
mical preparations, though employed from an early period as medicinal agents,
possess many deleterious properties which render them objects of some attention
during their administration, and they require to be used both internally and ex-
ternally with a due degree of caution,

The sulphate of zinc has some claim to our attention as a tonic, hut more as
ah emetic, and also as an application to the surface of the body in states of su-
perficial inflammation. As a tonic from one to three grains may very properly be
given in the course of the day; from one to twenty grains where its emetic powers
is to be obtained, and it very speedily operates; a larger dose may not prove so
injurious as an intermediate dose; in one instance a young lady accidentally swal-
lowed two ounces of white vitriol in solution, the consequences were immediately
visible. The countenance became pallid, the extremities cold, the eyes of a heavy
dull appearance, whilst the pulse fluttered; an acute pain in the region of the
stomach, accompanied with a sensation of burning, came on, violent vomiting
supervened; potassa was given in syrup, the pain gradually ceased, as did the
vomiting, and a complete recovery took place; on the other hand Fodere relates
that w'hich occurred to one of his patients, a custom-house officer, who obtained
from a druggist six grains of sulphate of zinc, with which he proposed to cure
a gonorrhoea under which he was at that time labouring, he was attacked with
inflammation of the lower belly, attended by retraction of the navel, and with
severe colic, w^hich yielded only to repeated abstraction of blood, both local and
general, to oleaginous emollients, and to the w^arm bath.

The very large doses that have been given in epilepsy without producing any
mischievous effects have been ascribed to the insensibility of the stomach, which
it would appear occasionally supervenes in that disease, and the same torpor has
prevented the emetic effect of very large doses of the sulphate of zinc, where
some of the most energetic of the narcotic poisons have been taken; it, however,
has been always considered the most useful of the emetics where an immedicte
emergency has demanded an active agent of this character, and it has obtained
the reputation of being the mildest of the metallic salts which provoke this
effect on the stomach.

Where epilepsy occurs early in life, and where there is reason to believe, from
the sickness, the nausea, the flatulence, the state of the bowels, and the loss of ap-
petite, that it is dependent upon disordered digestion, and that there is not direct
pressure upon the brain, an emetic of sulphate of zinc is frequently to be re^-
peated. Dr. Clarke, to whom we are so much indebted for a proper knowledge
of the treatment of the diseases of children, gives his recommendation to admi-
nister an emetic of sulphate of zinc in an aqueous infusion of ipecacuanha, and
to repeat itin six or eight or, ten days, according to circumstances. 'I'o a child
of four years of age, he has given six grains of the sulphate of zinc in half an
ounce of an infusion of fifteen grains of ipecacuanha in an ounce of boiling
water. In a child of two years old the dose will range from one to three grains
of white oxide of zinc; from one to six grains, where it is not intended to pro-
duce nausea and vomiting, but simply to produce the tonic effect which the metal

197

Materia Medica and General Therapeutics.

is capable of doing-. To adults, in chronic epilepsy of long- standing have been
given with very great success emetics of sulphate of zinc, at first once in the
week, then every fortnight, and gradually less frequently, until the paroxysms
have disappeared.

A curious case occurred at the North London Hospital; a female (one account
states her to be nineteen, another twenty-nine) was subject to epileptic fits,
which occurred almost every day for six months before she was admitted into
the hospital. She began with two grains of sulphate of zinc three times a day;
this produced a marked alteration in the fits, they were of shorter duration, but an
uncontrollable laughter and perpetual merriment were produced; the dose was in-
creased on the third day to four grains; on the sixth day to six grains; and at
last, between the 19th of March, and the 12th of April, to fourteen grains, three
times a day, when symptoms of gastritis were produced, which being relieved,
the medicine was again employed, but then five-grain doses could only be taken
any quantity beyond that being injurious to her stomach. During her submis-
sion to this treatment, it would appear that it had the most singular effect, that
of intoxicating her; the ultimate advantages or disadvantages of these large
doses, and of the sequela of the case we unfortunately could not become ac-
quainted with, for the misconduct of the girl caused her _to be dismissed from
the hospital.

Both the sulphate and the oxide of zinc have been very successfully given in
ghorea, and many very distinguished medical men have, at various periods, call-
ed our attention to them. At the Bristol Dispensary Mr. Bedingfield tells us,
some years ago, that out of forty cases that presented themselves, thirty-nine
were cured by the oxide of zinc, given in five-grain doses, three times a day,
gradually increasing the quantity to a scruple; probably the conclusion he drew
was such that cannot be assented to by all who have since had opportunities of
giving it a full and impartial trial; for he has said “ so speedily and decidedly
did this remedy put a stop to the disease, that I cannot avoid regarding it as a
specific for it.” Chorea occurs under so many extraordinary forms, and is ex-
cited by such a variety of causes, where there is any predispositiop to it, that
no one remedy can be declared to be decidedly useful. This disease appears to
occur very frequently in this country, or at least it is often developed at a later
period of life in females than formerly seems to have been thought. I have late-
ly seen some cases of it, to which the name of hysteria has been very injudi-
ciously given, as it has led to erroneous treatment.

Where chorea exists you will find the oxide of zinc, and the sulphate highly
serviceable, and where the disease is periodic they ma)’^ be given at the same
time with quinine, and with cinchona, with the utmost benefit. Out of nine
cases, five boys and four girls, seven were cured by zinc; w^here the disease,
however, arises from morbid derangements of the brain, where there is a ten-
dency to hydrocephalic action, where any external injury has given rise to the
disease, it fails of producing any beneficial influence. In pure hysteria it is hurt-
ful, generally injuring the tone of the stomach, producing nausea, a const-ant
tendency to vomit, and an increase of the malady.

The preparations of zinc have met with advocates in the treatment of intermit-
tent fever; and in various periodic affections zinc seems to approximate to iron
in many of its characteristics. It has been employed for hooping-cough, and
likewise for phthisis, but it has not gained any very great reputation as a cura-
tive agent in these diseases; it has, however, been found to restrain various of
of the haemorrhages, and more particularly the sulphate of zinc has been used
for haemoptysis, and for menorrhagia; in these states it has been usual to give
doses of a half to one grain every two hours until a nauseating influence is pro-
duced on the stomach, when it is to be discontinued, but again employed if
bleeding should recommence. It has been combined with digitalis, with conium,
and with opium, and administered in the form of pills, made with conserve of
roses, or dissolved in water. It has also been strongly recommended in dysen-
tery.

The external application of the sulphate of zinc has many claims to our no-

17*

198

Progress of the Medical Sciences.

tice; the only case of its proving fatal, when thus used, is related in Pyl’s Me-
moirs. The sulphate of zinc was used as a lotion for an affection of the scalp,
a scaly eruption; the patient was a child in good health, of the age of six. A
lotion, which was a vinous infusion, had not long been applied, before a burn-
ing acute pain came on in the head, death took place in five hours; previous to
which, violent vomiting, purging, and severe convulsions w^ere present; an apo-
plectic condition of the brain was found on examination after death. It appears
that the philosopher’s wool, or flowers of zinc, is not altogether free from dan-
ger; for the apprentice of an apothecary employed in preparing some, filled the
laboratory with the smoke. He wms seized with tightness in the chest; and
vidth vertigo; the following day he had vomiting and violent cough, together
with a sensation of stiffness in the limbs; the third day the vertigo had very
much increased, so that he could scarcely stand; he was affected, too, with some
degree of salivation, and complained of a coppery taste in his mouth; the bow-
els were severely griped; it was three weeks before he thoroughly recovered,
after having been actively purged, and having gone through a fever.

In some diseases of the skin, the local application of zinc has been found very
serviceable, more particularly where internal medicines have been employed, and
the constitution is but little affected in any way, where there is a chronic state
of debility of the dermoid coverings, but it should be aqueous solutions that
are to be employed; for in the greater number of instances in which it is mixed
up with fatty matter, and used as an ointment, it does more harm than good; in-
deed, the greater number of the metallic salts are much less useful when the
application is made in the form of ointment. The skin in long-standing cutane-
ous affections, will seldom improve from greasy substances; and, indeed, some-
times, when, on the first appearance of a papular eruption, this sort of remedy
has been used, the disease has become aggravated; simple solution of sulphate
of zinc, in distilled water, in the dose of a grain to one ounce, will often arrest
a local inflammation on the surface, and act as a powerful astringent; nor does
it possess any sedative quality. It is a very common and a very useful ingre-
dient in the different applications made to the eye to reduce the slighter inflam-
mations to which that organ is often liable.

Its action upon mucous membranes generally is of great importance; it re-
strains too copious a secretion from them; allays any irritation that may be pre-
sent; and has a very remarkable influence upon these tissues when they are in a
state either of acute or of chronic inflammation; hence its employment with so
much success in gonorrhma and in leucorrhcea, in the form of injection, and on
which I shall hereafter have occasion to dilate. In particular stages of these
diseases it is the most valuable remedy we possess, and can, with certain pre-
cautions, be prescribed with the utmost certainty. — Lancet^ March 17, 1838.

12. On the Properties and Therapeutic powers of Camphor, — By G. G. Sigmond,
M. D. Camphor produces several very extraordinary phenomena on the
human body. Mr. Alexander made some very curious experiments upon
himself with this substance. Having ascertained that no ill effects were pro-
duced upon him by swallowing a scruple, he took no less than two, mixed with
syrup of roses, in a single dose; before twenty minutes had elapsed, languor
and listlessness occurred; then giddiness, confusion of ideas, and forgetfulness;
all objects appeared to move before him, and a singular state of mind , terminat-
ing in unconsciousness; during this he was attacked by strong convulsions and
frenzy. Dr. Monro was called in, and by accident ascertained what had been
taken; he immediately gave an emetic, which brought away almost the whole
of the camphor that three hours before had been swallowed. Some time elapsed
before the mind altogether recovered its wonted state of tranquillity.

Professor Wendt relates an instance of a drunkard, who took no less than
four ounces of camphorated spirit, or a hundred and sixty grains, which had
been intended as an embrocation; his symptoms were very violent, but he recov-
ered, from the use of almond oil and vinegar, and there was no attempt at vom-
iting; and Hoffman gives us the case of a man who had swallowed by accident

Materia Medica and General Therapeutics,

199

two scruples of camphor, dissolved in olive oil, which brought on delirium, ver-
tigo, diminution of animal heat, somnolency, to which succeeded increase of
heat, accelerated circulation, and red-coloured urine; he gradually recovered.
Different have beerP the opinions as to its power: Cullen calls it a sedative, Ber-
gouzi a stipiulant, and Coruzzi a counter-stimulant. Hoffman endeavoured to
introduce camphor into general practice, and wrote “Dissertatio Medica de usu
CamphoraB inlerno Securissimo et Praestantissimo,” which first attracted the
attention of the profession; for, although previously there had been some physi-
cians who had prescribed it, camphor was by no means a favourite; it was “ a
cold medicine, and rejected,” as Dr. Lyons tells us, “upon that account, but
more especially, as it was thought, to extinguish all inclination or aptitude for
love.”

It was in fever of a malignant character, that in the quantity of ten or twelve
grains on the eighth, ninth, and eleventh day, to patients labouring under deli-
rium, fluxes, haemorrhage, petechiae, that it was most successful, according to
Riverius; and Hoffman gave it at the very onset of fever. It has since been
used, with great success, in fevers of the typhoid kind, in the dose from two to
fifteen grains; it has been also given in the different exanthemata, when they
have appeared in their worst forms.

Avenbrugger, to whom we are so much indebted for the hints given us,
which have led the way to the diagnosis of thoracic disease, published his
“ Observations on the Specific Powers of Camphor in the Cure of Mania,” in
the year 1776. Dr. Kenner, in the “Philosophical Transactions,” mentions
four eases of cure of insanity, effected by means of this drug. Fodere speaks of
it as quieting the nervous systerh, and unites it with bark; there have been
othqrs who have denied its possession of any power over mania; amongst these
Dr. Ferriar and Dr. Laughar. Still, previous to the paroxysm of mania, wflien
the premonitory symptoms announce the accession of violence, camphor should
invariably be administered, and from twenty-four to forty-eight grains in the
course of the day, may be safely used. It has been recommended, in hysteria
and epilepsy; but there ought to be great hesitation, as little doubt exists that it
has produced the last of these diseases. In 1814, a dissertation on this subject
was read before the Faculty at Paris, and epilepsy was attributed to the use of
this remedy. In such cases, it is evident that previous evacuations are neces-
sary, and it has been generally observed, that where constipation is present cam-
phor is rather prejudicial than otherwise. Dr. Lyons always recommended
after evacuation ten grains of nitre in combination with camphor, and as it pro-
duces thirst a quantity of some diluent drink afterwards, and he speaks of it as
a remedy, then, of the greatest value.

In puerperal mania camphor has been largely and successfully employed;
and Professor Berndt has recommended it in large doses; he found such decided
benefit from it, after many fruitless attempts to combat the disease by antiphlo-
gistics, ether, stimulants, and other remedies, that he was induced to consider
it as a real specific; he, however, recommends the application of leeches to the
head, and also to the inside of the thighs, in cases complicated with congestion,
and in plethoric constitutions. In gout and in rheumatism this remedy has ob-
tained Some degree of reputation; and more lately, in France, it has been tried
in these diseases in the form of vapour. M. Delormel and M, Dupasquier have
published, in the French journals, the results of their experience. One of the
most useful alleviators of pain during menstruation is camphor, triturated with
sugar; and in the dose of ten grains in the course of the day, it allays that high
degree of suffering to wdiich some females are subject during the periodical ex-
cretion. It has some claims to our considerations in various affections of the
mucous surfaces in which catarrhal discharges occur.

The camphor mixture of our Pharmacopoeia is one of the most serviceable
vehicles we possess for the administration of a great nunuber of the most active
remedies, which it renders less likely to be the cause of irritation, from its gen-
tle sedative influence. Although the quantity of the drug that is contained is
very small, it produces a very marked impression upon the nervous system; and,

200

Progress of the Medical Sciences.

while it corrects the too energetic action of a number of our therapeutic agents,
it assists others; thus it increases the action of the infusion of senna and of rhu-
barb, the decoction of aloes and of taraxacum, while it moderates the action of
the infusion of digitalis, or of tobacco. It is of infinite importance where medi-
cines are to act upon the kidneys, or upon the urethra; hence, where the infusion
of buchu, preparations of squills, of copaiba, or of turpentine, are to be used, it
is to be prescribed. The greater number of the diffusible stimuli, too, are
heightened by it; thus, combined with the liquor acetatis ammoniae, with the
compound spirits of lavender, with nitrous ether, it assists, corrects, and im-
proves them.

Our camphor mixture is formed of half a drachm of camphor, rectified spirit,
ten minims, and of water a pint; rub the camphor first with the spirit, then add
the water gradually, and strain through linen; although the whole of the cam-
phor is not taken up, yet there is the aromatic odour, the taste given to the
water, and quite as much of its medicinal power as is necessary. Of this most
valuable mixture two ounces may be given every three or four hours. The old
camphor julep, the favourite remedy of every Lady Bountiful, for every disease
in her parish, was thus made of camphor, one drachm, of the finest sugar, half
an ounce, boiling water, one pint; grind the camphor first with a little rectified
spirit of wine, till it become soft, and then with the sugar till it be perfectly
mixed; afterwards add the water by degrees, and filter in a close vessel; if the
composition be rubbed with twice its weight of gum arable, it mixes well with
the water. The emulsio camphorae of the Edinburgh Pharmacopoeia, supplies
the place of this formula; — Take of camphor, a scruple, sweet almonds blanched,
refined sugar, each half an ounce, water, a pint and a half, and make it in the
same manner as the common almond emulsion.

These are of use when blisters are applied; they prevent irritation in the uri-
nary passages. Though doses of camphor have been known to produce stran-
gury, of which Heberden quotes two examples; these have been said to have
the power of preventing the contagion of small-pox, of reproducing eruptions
that have been repelled, of preventing the narcotic influence of opium; and all
these preparations of camphor have their great admirers. Some medical men
declare the common camphor mixture to be the only vehicle in which medicines
that are to act as diaphoretics can, with a firm reliance on their action, be admin-
istered, without, from long continuance, a diminution of their efficacy.

The compound tincture of camphor is a useful anodyne, a fluid ounce contain-
ing nearly two grains of opium; it is the old paregoric elixir, and is formed of
two scruples and a half of camphor, of powdered opium, and benzoic acid, each
seventy-two grains; oil of aniseed, a fluid drachm, proof spirit, two pints; these
ingredients are macerated together for fourteen days, and then strained, and the
dose may be one or two drachms. The tincture of camphor is rarely used, and
then only externally, to excite the cutaneous vessels into action where they have
been long torpid; it is hence used occasionally to chilblains, more especially
when the itching is very severe; in chronic rheumatism, in slight indurations
around the joints, in local swmllings, in numbness, in paralysis, it has been some-
times used. It is made of five ounces of camphor and two pints of rectified spi-
rits; these are mixed, that the camphor may be dissolved. Whatever may be
the difference of opinion as to the nature of the action of this substance, when it
is internally administered, there seems to be but one judgment formed of its
very great utility as an external application, and it has some discutient as well
as anodyne powers, and liniments formed from it are amongst the most popular
remedies we possess; dissolved in oil, in alcohol, or acetic acid, it is used for a
vast variety of purposes, for bruises, for inflammation, for chronic rheumatism,
for indolent swellings, for infiltrations into the cellular substance; it is em-
ployed in poultices .for dysentery, for flatulent colic, for chronic indurations of
the liver: in the last disease, Maldonade has found it singularly serviceable. It
has been employed with much success in promoting the secretion of milk after
delivery; and a small bag, containing camphor, placed between the mammae a
few hours after the event, has been the practice pursued in France, on the recom-

201

Special Pathology and Special Therapeutics.

mendation of M. Dalle. The camphor liniment of London is formed of half an
ounce of camphor dissolved in two fluid ounces of olive oil. This, with the addition
of half an ounce of the solution of sesquicarbonate of potash, it appears, was
recommended by Mr. Ware to be applied to the eyelids night and morning in
incipient amaurosis. The compound camphor liniment is thus made: — Take of
camphor two ounces and a half, solution of ammonia, seven fluid ounces and a
half, spirit of lavender, a pint; mix the solution of ammonia with the spirit;
then, from a glass retort, by a gentle heat, distil a pint; lastly, in this dissolve
the camphor.

As an enema for worms, and for affections of the rectum, it has been used,
but requires to be prescribed with much caution. Heberden mentions that thus
administered it brought on pains resembling labour in a female; and I have men-
tioned to you the case of Dr. Edwards. Very shortly after the exhibition in this
form, the taste is decidedly camphorous, and the breath exhales the characteris-
tic odour, showing the rapidity of the imbibition and circulation throughout the
■whole of the system. It likewise may produce strangury in this form, as well
as in others. It is a singular fact, that it both produces and relieves this dis-
order.— Lancet, May 5th, 1838.

13. Value of Creosote as compared with other remedies. — There is an interesting
paper on this subject by Dr. Da Luz in the Journal da Sociedade das Sciencias
Medicas de Lesboa. The following are the author’s conclusions deduced from
his experiments: —

1. In indolent eruptions, not very extensively diffused, creosote is not more
efficacious than other remedies.

2. The long continued use of this remedy often causes an inflammatory con-
dition, which, however, has nothing in common with that of the disease which
is to be cured.

3. In itch, creosote is as efficacious as sulphur, tar, and common oil.

4. In tinea it is not more powerful than the preparations of sulphur and
emollient remedies in certain cases, and depilation practised according to Ma-
hon’s method.

5. It is an excellent cleansing remedy in atonic ulcers, but its prolonged use
hinders cicatrization.

6. In hospital gangrene it is the best antiseptic, and the most powerful means
of checking this frightful complication of wounds and ulcers.

7. Those condylomata, which are neither cured by emollient and tonic reme-
dies, nor by solution of corrosive sublimate, are not cured by creosote.

8. Creosote has no marked influence on the secretion of pus, and therefore is
useless in suppurating abscesses.

9. It has no power against caries.

10. It is an excellent styptic in capillary hemorrhage; but in hemorrhage
from great vessels, particularly when it proceeds from suppuration of the arte-
rial coats, it does not prevent a recurrence of the bleeding. — London Med. Gaz,
January 1838, from Zeitsch.fiir.g. M. September, October, 1838.

SPECIAL PATHOLOGY AND SPECIAL THERAPEUTICS.

14. Treatment of Irritation of the Stomach. — The following remarks on this
subject by Jonathan Osborne, M. D. of Dublin, are worthy of attention : “The
treatment of both acute and chronic irritation of the stomach, is to be directed,
1st, To the removal of its local causes, by the substitution of an appropriate
diet, and 2ndly, To calming the irritation already existing. The latter is affected
by, 1st, Dilution of the contents of the stomach; 2ndly, Diminution of its
sensibility, by the agency of cold or heat; 3rdly, The use of astringents in sedative
doses, as acetate of lead, sulphate of lime, nitrate of silver, lime-water ; 4thly,

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Stimulating- the circulation of the skin by means -of external irritants, bathing,
frictions, and exercise; 5thly, Stimulating the circulation of the pulmonary sur-
faces by changes of air; 6thly, Stimulating the nervous system by mental ex-
hilaration.

1. “ The removal of the local causes, hy the substitution of an appropriate Diet. —
When the mucous surface is irritated, it must be looked upon as in the same
condition as an irritated portion of skin, with regard to topical applications ; and
those substances which are most appeasing to the latter in the form of poultices,
are also to the former, as articles of diet. The food then should be vegetable,
and consist chiefly of amylaceous substances, as rice well boiled, arrow-root, &c.,
stirabout taken in moderate quantity, with milk diluted. It is, however, to be
observed, that stirabout lies under the imputation of causing heat and itching of
the skin, and justly so, those affections being peculi-arly prevalent where oatmeal
is much used. It is to be ascribed to a resinous matter, in the covering of the
grain, soluble in alcohol, which has been ascertained to produce this effect on the
skin. When meats are taken, they should be such as are most free from osma-
zome, as chickens, rabbits, sheeps-trotters, &c., and should always be accom-
panied by boiled rice or other vegetable matter, in order to diminish the stimu-
lating effect. Of all animal substances, that which appears not only to have no
stimulating effect, but actually to appease the stomach, is the yolk of eggs. I
was informed some years ago, by Mr. Daniel Moore, of the case of a lady
labouring under pertinacious vomiting, wdiieh he completely cured by frequently
repeated spoonfuls of raw yolk of egg, although it had been previously treated inef-
fectually, % a variety of the most approved remedies. Amongst the cases attached
to this communication, will be found an instance of vomiting from a congested
state of the stomach, in the last stage of diseased mitral valve, in which a-similar
success attended its employment. I could have added several others, and ray
failures with it have been principally in hysterical cases, in which, perhaps, it
is too disagreeable and disgusting, to be retained sufficiently long to exercise its
soothing properties. Eggs, in the form of light made custard-pudding, are
commendable; but having mentioned puddings, it must be remembered, that
all combinations of flour and butter, in which the latter has to be subjected to
heat, and then to be rendered rancid, are not only indigestible, and thus apt to
provoke a large secretion of sour fluids from the gastric glands, but are also in a
high degree irritating to the mucous membrane. Such are various kinds of
pastry, and to these may be added, the rancid oily nuts.

“ The articles to be avoided in these cases are, salt and sugar in their various
combinations. Even tea should be taken without sugar. In short, let the
patient suppose at each meal, that he is going to apply a poultice to the interior
of his stomach, and he will not go far astray. Let him also not overload, but
eat slowly, and about four times in the day, because mere weight acts as a
mechanical irritant, and is felt as a ‘load in the stomach.’ A habit of eating
quickly, is productive of over-eating, hence slow mastication must be strongly
insisted on, and in case of defective teeth, the food must be taken still more
slowly, and in a comminuted form. These observations appear trifling, but
w'hen we reflect, that the food has to come into actual contact with the irritable
surface, it cannot but be deemed of the highest importance that it should be pre-
sented in the least irritating form. In the whole series of stomach complaints,
the physician must have the direction of every thing which goes into the
stomach, whether as food or medicine ; and to be of real use to his patient, he
must be no less skilled in cookery than pharmacy.

2. Dilution of the Contents of the Stomach. — The effect of water taken into
the stomach, is to diminish the irritation of its contents by diluting them. Hence,
it is the usual custom to drink towards the conclusion of a meal. Another use
of dilution, and that which renders it a medicine, is to dissolve the mucus, and
thus to render the membrane accessible to astringent remedies. This effect is
best obtained by exercising after drinking largely of warm water. The mucus
is thus mixed up and dislodged. According to my view, this mode of action
explains the efficacy of mineral waters in irritability and chronic inflammation

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Special Pathology and Special Therapuetics,

of the stomach. When an invalid, at one of the German Spas drinks six or
eight beakers of the water before breakfast, and walks in the intervals, he washes
out the mucus, (as I have proved can be done in the dead stomach,) and thus
the small proportion of salts held in solution, acts on the membrane as sedative
and astringent. This view has to me been confirmed by experience ; as I find
that by administering one or more tumblers of warm water in the morning, then,
after exercise, giving the sedative astringents to be hereafter mentioned, the
most striking results can be obtained, and such as are usually only witnessed
during a course of mineral waters.

“ Another kind of dilution, is to mix mild along with stimulating articles of
diet. This is practised at our daily meals, when we use bread or vegetables in
alternate mouthfuls, with meats or seasoned dishes. An experienced gourmand
at a feast, will even venture to take things which he knows to disagree with
each other, if he has access to good stale bread, as by taking a quantity of this,
he is enabled to interpose such a substratum, as shall prevent them from coming
into immediate contact.

3. “ The use of Astringents in sedative doses, as Acetate of Z.ead, Sulphate of
Zinc, Nitrate of Silver, Lime-Water. — I merely state a fact, and am not proposing
a theory in describing astringents as a sedative to the mucous membrane when
applied in small doses. Let this be judged of by the effects produced, which
are diminution of redness, of heat, and of sensibility. Such effects are well
exhibited in the most approved applications to the conjunctiva of the eye, and
in gargles and lotions injected into the urethra. When the same substances,
however, are applied in an undiluted form, then chemical decomposition and
destruction of the membrane ensues. Seeing then the importance of attending
to doses in these cases, I shall state here, the forms in which I am in the habit
of prescribing those substances. They are as follows: — R. super acetat.
Plumbi, gr. xij ; Aceti ^ss; Aq. destil. ^viij. M. Sum. coch. ij. ampla mane
et meridie.

“To the above mixture, ah addition may be made of half a grain of acetate of
morphine, in case of general restlessness, or in case of the mucous irritation
being excited or aggravated by excessive secretion of sour fluid from the gastric
glands. In order to give the above and the two following formulae their full
effect, the patient should drink a large tumbler of tepid water on an empty
stomach, and use a little gentle exercise before taking the medicine. As for the
danger to be apprehended from the preparation of lead taken in this way, I can
State, that although now for years in the daily practice of writing the above
prescription, 1 have never seen one instance of either colic or paralysis resulting
therefrom.

“The acetate of lead formulae, I use in the earliest and more acute cases.
Next in point of astringency, and more applicable to chronic cases, is the fol-
lowing:— R. sulphat. zinci gr. iv; aqua destillat. ^ij. M. Sumat coch. ij.
ampla post aquae calefactae amphorum vacuo ventriculo mane et meridie.

“ The last of these formulae, and that most to be depended on in chronic cases,
which has also the advantage of being well suited to the cases of ulceration of
the stomach described in my former paper, is the following: — R. Nit. argenti
gr. ij ; Sacchr. alb. gr. iv. M. Ft. pil. viij.'' Sumat j. mane et meridie. With
the same directions as the two former.

“ The success obtained in hysterical and convulsive affections by nitrate of
silver, appears to me, to be derived from its astringent and sedative effect on the
mucous membrane of the stomach. It being decomposed very shortly after its
arrival there, by the free muriatic acid, and by the muriate of soda, causes it to
change its properties before it descends into the bowels, where it may eventually
prove a laxative. Both in chronic irritation and inflammation of the stomach, it
is an heroic remedy, the effects of which, only require to be aided by a judicious
attention to diet and the management of the bowels, in order to inspire the patient
with the highest degree of confidence in the resources of the medical art. The
discoloration of the skin, which causes female patients to regard the internal
use of nitrate of silver with great apprehension, I have never yet witnessed in

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Progress of the Medical Sciences.

any of my patients. The above mentioned dose, from being- speedily decom-
posed, appears to act merely as a topical application to the stomach, and as I
am not in the habit of continuing the use of it longer than a week at a time, the
absorption of it in an undecomposed form, and consequent deposition of silver at
the skin, appears next to impossible.

“ The last article mentioned, is lime-water. This is to be taken abundantly
as a drink, and mixed with milk or barley-water. I might also have included
the decoction of catechu and of log-wood, the latter especially, as being an
^agreeable drink ; but I have preferred to mention only those articles which man-
ifold experience has stamped with a peculiar value in my treatment of this
complaint, and leave to the judicious reader to supply the rest, by always bearing
in mind, that irritable or inflamed surfaces in the interior, resemble those in the
exterior with regard to those substances which come in contact with them.

“ The fourth, fifth, and sixth heads, embrace matters of the utmost importance,
and without which, all others will prove ineffectual in this complaint. Without
exercise in the open air, 1 have rarely seen permanent benefit obtained, and even
at the risk of cold and damp weather, the patient must go, out every day. Uhder
stimulation of the skin, is to be placed an application to which 1 attach a high
value, namely, that of mustard to the region of the stomach. The flour of
mustard simply mixed up with water, applied on a cloth over the stomach every
evening, and suffered to remain on until smarting is produced, is a powerful
adjuvant, and interferes with no other remedy. It also gives a temporary relief
from the pain coming on after dinner, and is generally most acceptable to the
patient ; it requires no dressing except dry lint or wadding. On the head of
mental exhilaration much might be said. Here the medicina mentis becomes a
most powerful auxiliary. Many physicians know no other remedy of this kind
but to send the patient to travel, forgetting how often it proves true, that coelum
non animum mutant qui trans mare currunt, and that in the stores of the imagi-
nation, even when remaining at home, there are many resources by which a
healthy interest in life may be excited, alternate employment and relaxation
provided, and hopes and expectations for the future enlivened. Of such impor-
tance is this, that the patient will not only imagine, but will, at least for a time,
actually derive more- benefit from a practitioner of high repute, whose words
sound like oracles, than from one of inferior eminence, although the prescriptions
of both may be the san^e.” — Duh. Jour. Med. Sci. Jan. 1839.

15. Neuralgia of the Testicle. — This is fortunately a rare disease, for it is one
of the most painful ones to which man is subject, and often a very intractable
one. Dr. Graves, in the Dublin Journal for January last, mentions two cases.
The first occurred in a young gentleman of highly irritable nerves, who had
studied hard and dissipated much. The paroxysms of pain did not observe any
marked period, but returned daily at uncertain intervals, which grew shorter and
shorter, until at hast he had scarcely any respite day or night. There was no
fever and not the slightest appearance of local congestion or inflammation. This
case yielded to large doses of carbonate of irpn freshly prepared, and frequent
inunction of the testicle and cord with belladonna ointment.

The second case occurred in a gentleman who laboured under neuralgic pains
decidedly of a gouty nature. In him the pain of the cord and testicles used to
come on every afternoon about four o’clock, and continued for several hours.
The pain was at times very severe. This neuralgia of the testicle disappeared
after a few days, and was replaced by a violent gouty pain in the loins and right
hypochondrium. The latter yielded to the usual local treatment and the use of
colchicum internally.

16., Method of preparing Sinapisms for the purpose of withdrawing Gout from
the vital organs to the extremities. — Dr. Graves says that the sinapisms usually
employed for inviting gout from vital organs to the extremities, act too quickly
to be long borne ; and of course only give rise to very superficial inflammation,
and that of very brief duration. To fix gout in a part, e. g., the foot, he adds.

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Special Pathology and Special Therapeutics,

our application must act much more gradually, and must excite the deeper seated
tissues. These objects may be obtained, he states, by mixing one part of strong
and fresh ground mustard powder with three of flour, and adding as much treacle
as will convert them into a viscid paste, which may be spread like a plaster on
linen, and applied to the part. This w'ill be borne for four or six hours, and
will cause a redness which will last a whole day. The proportion of flour may
vary according to circumstances. — Dublin Journal of Medical Sciences^ January
1839.

17. Treatment of Permanent Hypertrophy of the Tonsils. Dr. Graves considers
the best remedy for this affection, to be the nitrate of silver, and he prefers Mr.
Cusack’s method of applying it which is as follows: “The solid stick of lunar
caustic, or some of the latter in powder, and placed in a proper instrument, must
be kept steadily pressed against a particular spot of the enlarged gland ; two, three
or five seconds will suffice to secure the formation of a small eschar, which falling
out, will leave in the part, when healed, a slight depression like the largest pit
formed by a small-pox pustule. When this has been effected, which is usually
in about five days, a similar proceeding must take place wdth the other amyg-
dalae ; and so on in each, turn about, until the desired reduction of size has been
accomplished.” Dr. Graves prefers this method, to the use of the ligature or to
excision. When the glands are large, he says, this process usually requires
about six months; it is slow but sure; and must be intermitted when any acci-
dent gives rise to temporary sore throat or catarrh. — Dublin Journal of Medical
Sciences, January, 1839.

18. Spasm of the Glottis or Laryngeal Asthma. — The following case of this
complaint, recorded in the Lancet, (April 21, 1838,) by Dr. T. H. Burgess, is
worthy of attentive perusal. It furnishes important materials towards a better
understanding of a disease of great importance and of more frequent occur-
rence than is generally supposed.

“ Julia M. an infant between six and seven months of age, of an active con-
stitution and nervous temperament, and born of parents similarly constituted,
was attacked with that disease peculiar to infants, and variously designated by
authors — Millar’s asthma, crowing inspiration, spasmodic croup, &c. &c., in
January last, to such a degree, as to threaten immediate suffocation.

“ The infant, from its birth up to the accession of this disease, enjoyed per-
fect health; but it was observed from its earliest infancy to catch, or rather hold
its breath, when crying, which was attributed by the nurse to passion. How-
ever, this symptom was not paid any attention to, and appeared in the nurse’s
eyes of no importance whatsoever, for when the child’s health was inquired
after, the nurse usually observed, that she was remarkably well in every re-
spect, but she was very passionate. It is to be observed, that the mother’s milk
did not flow for several days after the birth of this child, that the infant was fed
with the spoon during this period, but from then until she was three months old,
fhe mother continued to suckle her, being at this time compelled to give up
nursing, in consequence of ill health, and from that period to the present, the
child has been brought up by spoon-feeding alone. I may here state, that, a
few days after birth, the thrush appeared, and passed away in the space of forty-
eight hours, without having occasioned the slightest uneasiness to the little pa-
tient during its progress, although there was a considerable quantity of flaky
mucus passed off by stool, still the disease was remarkably mild, and did not
appear to influence her health in the slightest. The infant was vaccinated twice
during the period she was nursed by the mother, and without the slightest ap-
parent effect, not even producing a blush in the vicinity of the punctures; she
was about six weeks old when vaccination was first attempted (the small-pox
being prevalent at the time,) and ten the second time. The child was frequently
observed, after taking food, and without the slightest exertion, to throw up from
the stomach a water brash-like fluid; this sometimes disappeared for weeks, and
No. XLVIL— May, 1839. 18

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Progress of the Medical Sciences.

then returned as before. Nothing worthy of observation presented itself in the
state of the child’s health, from the time of its being weaned until it was five
months old; the change of food produced no effect whatsoever at the time, at
least, no apparent effect; she was naturally costive, even from birth (her parents
being of the same habit,) and this derangement was neither increased nor dimin-
ished by the change of nutriment consequent on her being weaned. But it may
be here noticed, that, between the first and second vaccination, an immoderate
flow of saliva commenced, saturating several cloths daily, and continued until
the infant was nearly five months old; it then became suddenly suppressed, and
without any apparent cause whatever. The child’s health during this period
w'as, as before stated, remarkably good. It is worthy of remark, that from
the time when the flow of saliva first commenced, until it totally disappeared,
the holding or catching of the breath never showed itself and led the nurse to
suppose that her baby had got over her ‘‘passion fits' as she was wont to ob-
serve. All seemed going on well with the child, who being naturally quick,
was increasing daily in liveliness and vigour. On Christmas day, the over-fond
mother thought, as her baby was looking so remarkably well, and seemed in
the best spirits possible, that she would give her a ‘ morsel of plumb-pudding,’
which she avers was not as large as a nut, but it appears was saturated with
sherry wine. However, the child seemed nothing the worse of this for a few
day's, according to the nurse’s account. On Friday, the 5th of January, re-
markable for the dense fog which immediately preceded the severe frost, the
child was observed to be particularly uneasy and restless, and this being sup-
posed to have originated from derangement or irritation of the bowels, hydrar-
gyrum cum creta, gr. iij, were ordered to be given at bed-time, to be followed in
the morning by a teaspoonful of castor oil. This appeared to have the desired
effect in giving the child relief, and in quieting her restlessness, and for the next
week appeared in very good health. Just at this period the profuse flow of sa-
liva ceased, and the frost set in with great severity. On the 10th of January,
the child was observed again, and for the first time since it was weaned, to
‘ hold its breath,’ as if from passion; this appeared twice during that day, and
still without occasioning any alarm to the parent or nurse; it will be recollected
that this day (Wednesday, the 10th of .Tanuary) was the first of the severe frost.
On the 11th there was a tendency to catch the breath observed, but it did not
actually occur; the child’s bowels were opened by medicine twice or three
times during that day. On Friday, the 12th, the inclination was still stronger
than on the previous day to hold the breath, and a stifled passion-fit did occur
during the evening of this day. On the 13th nothing remarkable presented it-
self, excepting the child’s head being unusually hot. This being again attribu-
ted to intestinal irritation, rhubarb and magnesia was administered to the child
at bed-time, with apparent benefit. On the 14th, the head was still above the
natural temperature, but nothing else w*as observed; this day the weather was
extremely cold, snowing all day. On the following morning the child awoke
with a crowing fit, for the first time restraining her breath for near half a mi-
nute, and alarming the nurse, for now" she observed the infant’s face become con-
gested, and a blue rim appeared around the margin of both lips during the fit.
However, the child returned to her natural state in a few moments after, and,
seeming nothing the worse of what had happened, it was again overlooked, as
being of little moment. In the afternoon of this day, another fit came on as the
child was sitting in its mother’s lap, which the latter attributed to passion, in
consequence of her sitting down in place of walking about, this being the child’s
favourite amusement; this was also overlooked, and the mother only observed,
that the child should be broke of this evil habit in time. A third fit came on as
the child was being undressed this same evening, but disappeared almost in-
stantaneously on her being raised to the erect position. There were no symp-
toms of teething present, the child was not irritable in the slightest manner,
and, excepting this peculiarity, seemed in the best possible health. On the 16th,
a day of severe frost, so much so that the wmter wms frozen in the basin of the
child’s apartment, although a fire was kept constantly burning there, no fit ap-

207

Special Pathology and Special Therapeutics.

peared on waking- in the morning, and during the whole of this day only one
mild attack came on; but the child’s head was observed to be extremely warm,
in consequence of which the mother was led to take off the cap for awhile, that
the heat rtiight subside, thinking that the extreme cold of the atmosphere would
soon reduce its temperature. But this was not of the slightest avail, although
persisted in for two hours, and the mother then gave the child a powder as be-
fore, containing rhubarb and magnesia, which produced two motions, and consi-
derably abated the inordinate heat of the scalp. On the morning of the 17th,
the child had a mild paroxysm as it was being dressed, this was about nine
o’clock; there was an interval of two hours between the first and second fit,
the latter being more severe than the former; another fit, still more severe than
the two previous, appeared after the lapse of one hour, and the nurse, suppos-
ing it to be the effects of passion, attempted to subdue it. The disease again
returned in or about half an hour after the last attack, and was repeated every
half hour until two o’clock; at this time it assumed a much more serious aspect,
and the fits recurred in quick succession (the intervals between each being
about ten minutes,) continuing in this state for the space of an hour at least.
The family medical attendant saw the infant in one of those fits on this day,
and for the first time. He had not seen the child for two months before, and
on looking at the head, thought it very much enlarged; it was also considerably
above the natural temperature on this day, which led him to think those ‘fits’
were owing to efiiision at the base of the brain, and were probably the precur-
sors of convulsions, which he said was to be obviated by the timely application
of leeches behind the ear, by the use of the warm bath, and by aperients, such
as hydr. c. creta, in two grain doses, all of which was adopted on that evening.
It is worthy of observation, that a few moments before the leech was applied,
the child had a severe attack of the disease while sitting quietly in the nurse’s
lap; that on the application of the leech the child screamed violently from the
pain of its bite; and during this time not the slightest symptom of the disease
appeared. This exemption from the disease was remarkable throughout this
case, whenever the child was irritated so as to scream violently; and on this and
other peculiarities we purpose commenting, after detailing the facts of the case.
From the difficulty of stopping the bleeding of the leech-bites, the infant lost
more blood than was intended; still the heat of the scalp continued unmitigated;
but about two or three hours after the administering of the hydr. c. creta (the
nurse by mistake having given two powders instead of one), a copious evacua-
tion was produced, which succeeded in diminishing the abnormal heat of the
head, that had now continued for thirty hours. After the haemorrhage ceased,
the infant fell off into a tranquil sleep — the sleep of exhaustion, and which con-
tinued undisturbed for six hours; when the child awoke from this slumber it
was unusually restless, but the disease did not appear on her waking; the head
gradually resumed its former morbid state of heat, and a throbbing of the fonta-
nelles was particularly evident. The medical attendant ordered the head to be
uncovered during the d-ay and the body kept cool.

“ I saw the child in a mild fit on this day; but thought the disease was totally
unconnected with any cerebral affection. I stated my opinion, that it was a
nervo-laryngeal affection, probably spasm of the glottis; that the exciting cause
was derangement of the alimentary canal, arising from costiveness. 1 lanced
the gums immediately, in case dental irritation was a cause of the disease, pass-
ing the instrument as deep as the maxilla, but there was not the least appear-
ance of teeth, the child being now ne-ar six months old. During the two fol-
lowing days, there was no recurrence of the disease, but about two o’clock on
the third day there was a severe fit of crowing.

“There was no apparent cause for this attack, and it came on whilst the little
patient was sitting quietly with its nurse. I saw the child during this fit, and
was convinced th-at it was a well-marked example of the disease commonly
called the ^crowing inspiration of children' &c., and of a purely nervous cha-
racter. Any individual who had once seen this affection could never mistake it
again for any of those dise-ases incidental to the infantile age. On the 22d, 1

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Progress of the Medical Sciences.

had a consultation with Dr. Marshall Hall respecting this disease, when it was
agreed that if possible the child should be provided with a young and healthy
nurse; and if this could not be acquired, asses milk might be substituted; that
the gums were to be freely lanced at least once a week, and the bowels kept
regular by mild aperients. Dr. Marshall Hall did not at this time see the child
in a fit of the disease, but from the description given was convinced of the ex-
istence of the affection under consideration; the warm bath was also recom-
mended every other night, and strict attention to the antiphlogistic plan as re-
gards nourishment. By this treatment the disease was w’arded off until the
evening of Monday, the 29th, when the child had a very severe attack, border-
ing on convulsions; she was immediately put into a warm bath, which perfectly
relieved her for the time being; and after taking a powder containing rhubarb
and magnesia, fell asleep in the nurse’s arms.

The child now, for the first time, began to evince symptoms of terror at each
accession of the disease; formerly she never appeared in the least degree alarm-
ed before or after the fits. No medical man saw the infant this evening; and
as she appeared quite well next morning, the mother thought it unnecessary to
have medical advice. During the next four days the disease appeared only
three times, but the fits were of much longer duration than any of the preced-
ing. On the 5th of February, the disease being aggravated, Dr. Marshall Hall
and myself again saw our patient. During our visit the child had two severe
fits of the disease; these were the first which Dr. Marshall Hall saw this infant
have, and was now convinced that there was no cerebral affection existing as a
cause of this disease. He also agreed with me in attributing it solely to a de-
rangement of the alimentary canal, the motions being black and slimy, without
a tinge of bile, and these produced with difficulty, even by the aid of medicine.
The bowels were ordered to be briskly purged, and Dr. Marshall Hall recom-
mended hydrocyanic acid as an antispasmodic, in the proportion of a minim to
the ounce, a teaspoonful to be given occasionally after the bowels were acted on.
I saw the child early next morning, and was informed by the nurse that the me-
dicine had opened twice, but the motions were still dark and scanty; that she
had administered the hydrocyanic acid once only since the bowels were opened,
and only one crow came on during the night.

“ The child was sleeping when I made my visit; the breathing was evidently
laborious, and sometimes stertorous during the time I was present. The child
awoke after the lapse of ten minutes, crying, but had not an attack of the dis-
’ ease. I could now perceive a peculiar rudesse dc la votx, or raucity of voice,
especially in the act of crying, and which was not at all observed before this
day. After walking about the room for a few minutes, the nurse proceeded to
administer the hydrocyanic acid a second time, and with great difficulty could
get the child to take it. From the irritation produced by forcing the little patient
to take the acid mixture, a paroxysm of the disease was brought on, which
began like one of the mild attacks that were heretofore observed, but rose gra-
dually to a fearful height. The first evidence the child gave of the approach-
ing spasm was by bending the body forwards^ as in emprosthotonos,* and not
backwards, as Dr. Clarke observed in the cases he relates. She seemed gasp-
ing for breath, and darted her head on all sides, as if seeking for air. There
was now a momentary pause, in which the respiration was totally suspended;
and this was immediately followed by a sound deep in the larynx, resembling
the ‘ death rattle^'' or the rushing of waters, which led me to suppose that some
of the liquid had passed into the air passages.

“ The face now assumed a purple cast; the eyes were uplifted, presenting
that peculiar appearance denominated pathetic the pupils were widely dilated,
and a deep blue, or livid areola appeared around the margin of the lips and eye-

* Dr. Marshall Hall had never seen this state of contraetion before: and this is the
case lie alludes to in his last lecture, where he states “the fifth case I saw there was
emprosthotonos and contraction of the pupils during the spasm, with dilatation after-
wards.”

special Pathology and Special Therapeutics. 209

lids; the body was still bent downwards, and rigidly retained in that position.
The thumb was clenched in the hand; the arms and legs were strongly con-
tracted; in a word, the entire body was in a state of the most rigid spasm. The
gurgling sound of the air passages terminated in two or three impeded attempts
at inspiration, which were at length followed by a long, loud, and shrill crow-
ing inspiration, resembling that of pertussis; and the little sufferer, instead of
crying, as formerly, now, from the extreme exhaustion, fell over in the nurse’s
arms, into a deep slumber; at first the breathing was heavy, but it soon became
perfectly tranquil, and in this way she reposed for near one hour. The follow-
ing four days the paroxysms were milder, but more frequent than heretofore;
and on Saturday, the 10th, they became greatly aggravated, and the danger of
asphyxia was extreme; towards the evening of that day a violent paroxysm
came on, far surpassing any of the former; the child lay perfectly stiff in my
arms for some moments, and in this state, ivith her clothes still on, 1 plunged her
up to her middle into a warm bath, which was ordered to be kept in readiness
in case of any emergency. Dr. Tweedie came in just as the child was being
removed from the bath, and was present during two paroxysms of the disease.
I omitted saying that the fit previous to the warm bath being used terminated in
convulsions, the first and last time during the progress of the disease, that they
appeared.

“ Dr. Tweedie thought the disease was now at its height, and the infant’s
life was inconsiderable danger; that during the paroxysm nothing could be done
to alleviate the sufferings or avert the danger of strangulation, and they must
only be allowed to take their course; and owing to the great torpidity of the
bowels the most active remedies must be had recourse to. During the last four-
and-twenty hours there was only one scanty motion, dark-coloured, and of the
consistence of putty, although the child had taken three powders within that
space, containing one grain and a half of calomel, with five of the dried car-
bonate of soda. The mercurial purgatives will be found, in general, improved
in their action by the addition of this alkali, and followed up by a teaspoonful
of castor oil. It was now agreed upon that one grain of calomel, three of scam-
mony, and three of rhubarb, in the form of a powder, was to be administered
immediately, and in two or three hours after a teaspoonful of the common black
mixture, should be given; if this did not operate the powders were to be re-
peated until the bowels were moved. Injections of warm water having failed
repeatedly on former occasions were not resorted to on this. The powders and
black draught were administered twice, and after the lapse of eight hours and a
half one dark-coloured motion was produced. The medicine not operating, as
was expected, though six powders of the above strength were administered
within the twenty-four hours, I changed the three grains of rhubarb for three
of jalap next day, after a single dose of which the bowels 'were copiously dis-
charged.

“ At the mother’s anxious request, I sat up all night with my little patient,
as she dreaded the convulsions again coming on. However, nothing serious
occurred in the night, but towards morning the child had two modified attacks
of laryngeal asthma, the disease having evidently yielded to the influence of the
medicine that had been administered. The powders were repeated every four
or six hours from the last dangerous attack, until the disease was greatly
abated. There was no accession of the paroxysms from Saturday evening until
Monday evening, the 12th of February. Dr. Tweedie saw the child this day,
and considered her greatly improved. He was surprised that her spirits, which
were still active and lively in the extreme, w'ere not in the slightest affected by
the brisk and continued purgation, and the exhaustion produced by the disease
itself when the paroxysms were so frequent and severe. On the morning of
Tuesday, the I3th, the little patient not having had any medicine for nine hours
previous, evinced a tendency towards the crowing inspiration again, the same
peculiar rudesse de la voix as before mentioned, became again apparent. The
calomel and drastic purgatives were immediately administered, and after the
lapse of two hours, during which the crowing tendency continued, a copious

18*

210

Progress of the Medical Sciences.

evacuation (but still unhealthy) was produced; four hours after the last was
given another w’as repeated, which also operated briskly, and the motions were
not quite so dark as before, but still not natural; each of these powders was
followed in due time by a spoonful of the common black draught to accelerate
their action.

“ Dr. Marshall Hall now strongly urged change of air for the child, as he
had two little patients within the last season, which were quite recovered by it,
after the use of medicine. However, the inclement state of the weather at the
time would not permit of an immediate change, and the child was now swathed
in flannel, and the heat of the room was regulated by the thermometer to be-
tween fifty-eight and sixty degrees of Fahrenheit. 1 find nothing particular
noted down in my case book during the three following days (those are the
14th, 15th, and IGth,) respecting the disease, but that the bowels were still kept
freely open by the same remedies. On the 17th, I was wishful to substitute a
mild aperient— hydr. c. creta, for the very severe remedies which had now been
used for a week; accordingly the former medicine was administered in three
grain doses, three times during the ensuing twenty-four hours, but without any
effect, and the evidence of approaching spasm being again apparent, I imme-
diately had recourse to the drastic purgatives, which operated after three hours,
and banished the threatening symptoms of the disease.

“ On the 18th, the child appeared uneasy and restless, but no appearance of
the disease presented itself, and 1 again lanced the gums, being the third time
since the disease assumed its dangerous aspect. The only medicine that was
administered this day was a teaspoonful of castor oil, which operated mildly on
the bowels.

“ On the 19th and 20th the child was doing well, and lively in the extreme.

“ I saw my little patient on the 21st, at noon, and the disease appeared al-
most gone. The nurse informed me she had only one paroxysm within the last
twenty-four hours, and that the bowels were opened twice during the same time
without the aid of any medicine. I now strongly urged the mother to remove,
for even a few weeks, to one of the villages around London, and this she ac-
cordingly did on the following day, February 22d. Although the first week
after the removal to the country, the weather was very severe, still the child
appeared benefitted considerably by the change, as not a single crowing inspi-
ration was observed during that time, notwithstanding her being confined to her
nursery from the day she was removed until the 1st of March. The bowels
were still torpid, and an occasional mild aperient was necessary to keep them
open; but from this time until the present nothing of any importance occurred
(excepting one threatened paroxysm) in the infant’s hygiene, the disease appear-
ing to have altogether subsided, and the little patient is now daily progressing
in health and vigour.

“The following facts, detached from the history of the preceding case, are
those which particularly demand our attention.

“ First. — That the infant, from its birth, evinced a tendency to spasm of the
larynx.

“ Second. — That during the continuance of the profuse flow of saliva, this
tendency to spasm totally disappeared, from which it would appear that denti-
tion was the cause of it, more especially as the symptoms reappeared on the
suppression of the discharge.

“Third. — That the spasmodic paroxysms assumed a quotidian form, recurring
at two o’clock each afternoon, /or some days, and disappearing during the inter-
mission.

“ Fourth. — That there was no cerebral affection whatsoever as a cause of this
disease.

“ Fifth. — That the irritation produced by crying, or screaming violently, sel-
dom or never brought on a paroxysm of the disease, this being contrary to all
other recorded accounts of the same affection.

“ Sixth. — The emprosthotonie contraction of the body, in contradistinction to
the cases narrated by Dr. Clarke and others.

211

Special Pathology and Special Therapeutics,

“ Seventh. — The contracted of the pupils during the paroxysm, and dila-
tation afterwards, which state I believe has not been hitherto recorded, except
in last week’s Lancet, "where Dr. Hall alludes to this case in his lecture.

“ Eighth, and last. — The obstinate torpidity of the bowels, which in this in-
stance appears to be, without doubt, the real exciting cause of the disease.”

19. Efficacy of Emetics in removing Paralysis of the Facial Nerve, — Dr. C. J.
Heidler, of Marienbad, relates in Rust's Magazin^ (Bd. xlix. Heft 2.) the two
following cases to show the efficacy of emetics in removing paralysis of the facial
nerve. We have several times witnessed their utility in our own practice.

Case 1. A man, aetat. 44, of rather feeble constitution, complained of a feeling
of fulness in the head after a morning of rather severe study. In the afternoon,
during an excursion to the country, he exposed himself to cold, and on his return
home- became aware of a vslight difficulty of rounding the mouth in spitting.
This symptom gradually increased till the case assumed the aspect of a mild
form of paralysis of one side of the face. There was still slight congestion of
the brain, and the whole vascular system was a little excited. The tongue was
affected only in a slight degree. The diagnosis was— a congested, or perhaps
an inflammatory state of the root or trunk of the facial nerve. Venescection of
twelve ounces, a blister to the nape of the neck, cold applications to the head,
and an emetic. The only immediate consequence of these remedies was the
partial relief of the congestion of the head. The patient passed a good night;
but on the second day the paralysis seemed to have increased rather than have
diminished : leeches were, in consequence, applied behind the ears and to the
nape of the neck, and sinapisms to the feet; the cold applications to the head,
w^ere continued. In the afternoon a blister was applied behind the ear ; the back
and the calves of the leg were drycupped, and a drastic purgative prescribed;
but these measures failed in producing any apparent diminution of the paralysis.
On the afternoon of the third day, another venesection of ten ounces was made,
in consequence of a return of the symptoms of cerebral congestion ; ice was
kept applied to the head, and in the evening an emetic was administered. This
was followed in some hours by a sensible diminution of the paralysis and the
disappearance of the cerebral fulness. On the fourth day warm cataplasms
w’ere applied to the affected cheek; but cold applications to the head were
repeatedly substituted, when the symptoms of congestion threatened to appear.
On the fifth day there were again slight congestion, for which leeches were
applied, and an emetic given in the evening, but without in any degree removing
the paralysis. On the sixth and seventh days the warm cataplasms were
occasionally applied, and anather emetic was administered in the forenoon of
the latter day, which produced copious vomiting. In the evening the patient
regained some power over the affected muscles, and during the two following
days it continued to increase ; the warm cataplasms being occasionally applied.
On the eleventh day another emetic was ordered, which produced still further
diminution of the paralysis, which eight days sufficed to remove entirely.

Case 2. A woman aetat. 40, of weak constitution, was affected with violent in-
flamation of the left ear, which apparently extended to the brain and correspond-
ing facial nerve, leaving, after its removal, a total paralysis of the muscles of
this side of the face. Four weeks after the inflammation had ceased, all the
branches of the facial nerve, but particularly its trunk immediately after its exit
from the cranium, still showed considerable sensibility on pressure. The brain
was affected in a slight degree, and the whole of the leftside of the head felt
tight and uncomfortable. The commissure of the mouth and the eyeball were
nearly immoveable, and considerable difficulty was experienced in moving the
eyelids, which during sleep remained half open. The intellect was slightly
affected, and a feeling of numbness in the hand and foot of the affected side gave
rise to suspicions of threatening apoplexy. Such was the state of the patient in
the sixth week after removal of the inflammation, notwithstanding the energetic
employment of counterirritation and other remedies. A slight indigestion was
at this period the cause of an emetic being administered, which had the effect of

212

Progress of the Medical Sciences.

producing a sensible diminution of the paralysis. The patient made no further
advance towards recovery during the next eight da)^s : a second emetic was then
exhibited, which was followed by a similar diminution of the symptoms. Seven
emetics were thus successively given at longer or shorter intervals, with the
linal result of removing completely the paralytic affection. — B. ^ F. Med. Rev.
Jan. 1839,

20. Hepatic Mscess.—SVe transfer to our pages from the India Journal of Medi-
cal and Physical Science^ (July? 1838,) the following table of 41 fatal cases of
hepatic abscess, with the interesting remarks appended to it, by Dr. Jackson,
the Surgeon to the Regiment.

Table of fatal cases of Hepatic Abscess, which occurred in H. M's. sixth Regt.
at Colaba, Bombay, from July, 1836, to Dec. 1837.

Number. I

tJO

( Years in India.

Head

1 of

1 Admission.

Number ot days
in Hospital.

1 Number.

e.'

bjo

1 Years in India.

Head

Admission.

Date

Admi.ssion.

Number of days
in Hospital.

! 1

Dysenteria ac.

1 1 July, 36

Hepatitis ac. '

3 April, 37

Hepatitis chr.

Dysent. -

Idem.

30 Nov. “

Hepat.

Hapalitis ac.

5 Dec. “

Pneumonia

7 May, “

1 5

Idem.

Hepatitis ac.

! 6

Idem.

Dysent. ac.

Idem.

111

Idem.

Hepatitis

25 “

111 Hepat. ac.

25 “

Idem. chr.

8 June, “

lio

Idem.

3 Jan. 37.

Idem.

27 “

ill

12 Dy sent. ac.

32 39

Idem.

7 July, »

!i2

2 Idem.

33|33

Dysent. ac.

13 32

11 Hepatitis chr.

21 “

34 37

Hepatitis chr.

108

14-30

11 Idem. ac.

35 39

Dysent. ac.

3 Aug. “

15 38

12 Dy sent. chr.

8 Feb. »

36 37

Idem.

10 ■“

16 33

9 Idem.

133

37,32

Hepatitis ac.

25 8 pt. “

17 45

12 Idem. -

3841

Dysent. chr.

1 Oct. “

1847

Idem.

39 36

Idem.

9 Dec. “

19 33

12 Hepat. ac.

5 Mar. “

40 22

Idem.

20 39

21 Dysent.

41 30

Hepatitis ac.

21 46

22 Idem.

“ Here is a frightful table of casualties from one disease ! ! against which I can
scarcely bring a well marked case of a similar nature terminating in recovery.

“ The disease was insidious, and the symptoms obscure, seldom in the first in-
stance referrible to the seat of the disorganization. In the worst cases pain in
the side was either absent, or so slight as not to be complained of by the patient.
In many the figure of the right side of the trunk was perfectly natural. Again
in others there was an enlargement in the Epigastric and right Hypochondrial
regions, varying from a slight fulness to an enormous bulging out, and the latter
generally took place suddenly. '

“The symptoms most characteristic of the disease were, irregular paroxysms
of fever, with profuse clammy partial perspirations. Pulse remarkably soft and
compressible, sleepless nights, total loss of appetite, sallow or livid countenance,
features shrunk. Tongue of a dark green colour, often without fur, sometime^
morbidly clear. Taste vitiated or lost. Urine scanty and of a high colour, ex-
treme whiteness of the skin, particularly of the hands. Emaciation and depres-
sion of spirits.

213

Special Pathology and Special Therapeutics.

“There was nothing remarkable in the stools on admission, but flux generally
supervened. The patient complained of sense of emptiness in the epigastric
region, which he in vain attempted to relieve by swallowing what ingesta he
could. There was no pain on pressure, but inability to lie on either side: im-
peded respiration, dulness or percussion of right side of tiie thorax and absence
of the respiratory murmur. Pain shooting up the right side of the walls of the
thorax and affecting the scapula and shoulder was a common symptom.

“ No. 37 and two other cases had been in hospital for indescribable anomalous
complaints, under the head of dyspepsia, remained for several weeks, when some
of the above symptoms indicated the formation of matter. Others apparently
well in barracks, or so slightly ill as not to be aware that any thing was the
matter, remained so until the disease suddenly assumed a serious aspect, and the
patient was admitted in a state of collapse.

“ Some had been the subjects of previous attacks of hepatitis: in these it was
presumed, that an acute attack supervened, while the organ was in a state of
chronic inflammation, or softening and ran rapidly into suppuration.

“ In several of the casualties under the head of dysentery, abscess was not sus-
pected during life. In almost all the cases of hepatitis, the diagnosis formed at
an early period, from the general symptoms and history of the case, turned out
but too correct; the more immediate cause of death was hectic fever or colliquative
diarrhoea, and this event generally took place before the abscess burst. They
generally pointed (when this did take place) on the epigastric or infra mammary
region between the ribs. In three cases the abscess was opened: only one of
these recovered. Opening them generally accelerated a fatal termination by
aggravating the irritative fever. Two cases, not included in the above table,
came under my care: both were opened. From one, a hundred ounces of pus
came away the first 20 minutes, and 350 more next day, w^hich afforded only
temporary relief.

“In none did the abscess burst externally, nor into the intestine, in one into
the lung, in one only into the peritoneal sac.

“ Upon inspection of the bodies after death we often found destruction of the
whole right lobe of the liver, involving the peritoneal lining posteriorly. The.
right lobe was more frequently the seat of abscess than the left. In some there
was one or two large abscesses, in others a number of small ones, of different
sizes, generally not communicating with each other, lined by a cyst of different
degrees of consistence, in some semi-cartilaginous, in others thin. The contents
varied in colour, consistence, and appearance. These were thin, serous, icho-
rous, milky, flaky, jelly-looking or of the consistence of healthy pus, and often
containing large portions of degenerated liver. Those portions of the liver not
involved, were of a grayish colour and in a state of softening. The substance of
the gland immediately surrounding an abscess did not differ in colour or mecha-
nical properties from the other parts. In No. 25 Pneumonia, the diagnosis was
altogether wrong, the patient had been ill many days under canvass and in ship
board his left lung was nearly obliterated by the abscess pushing up the dia-
phragm and extending as high up in the chest as the second or third rib.

“In No. 14 the patient expectorated pus many days before his death; upon a
careful post-mortem examination no communication between the liver and lung
could be traced. In two-thirds of the. fatal cases of dysentery last year, hepatic
abscess was found to have co-existed. It is worthy of remark that when we
had the greatest number of cases of hepatic abscess, there were remarkably few
cases of abscess in other parts of the b^ody, scarcely any not even boils.

“ From the table it appears that the majority of these fatal cases occurred in
men who had been ten and twelve years in India and who were between 30 and
40 years of age. Seven were upwards of forty, while four v/ere recruits.

“ Some of the patients evinced symptoms of scorbutus, and I suspect that in
all of them a latent scorbutic diathesis existed to a greater or less extent. Scorbu-
tic hepatitis is as reasonable as scorbutic dysentery, and perhaps the term is as
expressive of the nature of one disease as the other. This scorbutic taint may

214

Progress of the Medical Sciences,

have been complicated with a purulent diathesis pus separated from the blood
without previous inflammation and deposited in an organ in a state of softening.

“ With regard to the treatment, our principal indications were, in the first place
to do no harm and to avoid the debilitating influences of medical treatment, then
to keep the patient alive as long as possible by inspiring him with a false confi-
dence in placeboes. The system was totally insensible to the influence of mer-
cury as sialagogue.

‘‘ However, leeches in moderate number, baths, sinapisms freely applied, ano-
dynes, laxatives, and stimulants were found highly serviceable and were admi-
nistered pro re nata. Vy. was inadmissible. Sudorifics and diuretics were of
use.

“ I have seen a patient recover from the following symptoms indicative of hepa-
tic abscess, viz. heavy dull pain in hepatic region, an enormous swelling in the
right hypochondriac and epigastric regions, green tongue, soft pulse, restless
night, flux, &c. A few doses of calomel and blue pill as purgatives were admi-
nistered, but without any hope. or object in producing salivation.

“ It appears that the total number admitted under the head of hepatits was
twenty, the same number under that of dysentery and one under that of pneu-
monia.

“ The number or size of the abscesses, are sufficient to account for its fatality.
1 can easily fancy a man recovering from one moderate sized abscess, bursting
internally or punctured. In those cases contracted in hospital, and in which the
disease was early suspected, the treatment was as unsatisfactory as in serious
cases admitted from Barracks.

The subjects of many of the above casualties were known to have been hard
drinkers, but none of them, Dr. J. says, indulged to such excess as to have been
subject to delirium tremens. “In several of the worst cases,” he states, “the
patient seriously declared, that he had npver experienced pain in the side, nor
did they even allude to any w’eight or uneasiness in that region. I strongly sus-
pect the fact to have been, that their feelings of health and disease were com-
pletely marked by the operation of arrack, until the disease suddenly exploded,
and they were admitted in a state of collapse.”

21. Case illustrating the History^ Symptoms, Pathology and mode of Treatment of
Simple Ulceration of the Stomach. By Langston Parker, M. R. C. S. A remark-
ably stout man, a free liver, in the middle walks of life, began to suffer from un-
easiness after taking his food at the age of eight and twenty years. He then suf-
fered from weight, distension, and flatulence, with nausea after eating; he had
also occasional vomiting. These attacks were relieved by medicines prescribed
for him by the physician, under whose care he was at that time placed, but were
prone to recur when the patient returned to his customary habits of living.
When I first became acquainted with him, eight or ten years ago, he com-
plained of fixed pain in the epigastric region, which was much increased by
pressure and taking food; the pain was not at that time constant, it w^as most
distressing after eating, and accompanied by much flatulence and distension.
By restricting the patient to a milk and farinaceous diet, sponging the epigas-
tric region frequently during the day with hot water, and exhibiting some mild
carminative aperients daily for a short time, the symptoms subsided, and he
again returned to his occupation in apparently good health.

After a time the pain again returned in a more violent and obstinate manner
than before. It assumed the same chariicter, was worse after eating, and ac-
companied by some tenderness and heat in the epigastrium. It did not now
yield to the remedies which had before relieved him, but was much mitigated,
and for some time entirely disappeared after the application of small relays of
leeches, and continued counter-irritation over the epigastric and left hypochon-
driac regions.

My patient again returned to his accustomed occupations and mode of living,
and after a lapse of eighteen months returned again with his pain as bad, if not
worse than before. He was again relieved, I may say cured of his distressing

215

Special Pathology and Special Therapeutics.

uneasiness, by the administration of small doses of the muriate of morphia, and
a repetition and continuance of counter-irritation; observing, at the same time, a
strict dietetic regimen.

In this manner, during the last ten years of his life, was this patient relieved
or cured six or seven times of the painful affection of his stomach, which as
constantly returned, when he resumed his customary habits of living upon
mixed and stimulating food and drink.*

After having lost sight of him for some time, during which period his ail-
ments were so slight as not to lead him to seek medical assistance, I was sud-
denly C9,lled to him during a violent attack of haematemesis, in which he vomit-
ed from two to three pounds of blood. I may here observe that, during the
previous progress of disease, my patient had never vomited blood, or those
black discharges which are peculiar to ulceration of the stomach. He had
rarely nausea, and if he had an attack of vomiting, which did not take place more
than two or three times during the whole progress cf his disease, he vomited his
food only. He was, however, occasionally subject to discharges of blood by
stool, and at other times when this was not the case, his stools were black as
pitch; these black discharges we shall afterwards speak of, but when they occur
with such gastric symptoms as the present, and independent of any haemor-
rhoidal or other disease of the rectum or anus, they are symptoms indicating very
strongly the existence of ulceration of the stomach.

To the vomiting of blood succeeded great languor and depression, palpita-
tions, hurried breathing, with attacks of severe pain in the stomach and bowels,
which came on daily, sometimes twice or thrice in the twenty-four hours. The
pain seized him suddenly, and left him with a discharge of wind. He had
great tenderness and pain in the epigastrium and right hypochondrium; the
skin had a pale, sallow, blanched appearance, whilst the tongue did not devi-
ate in any appreciable manner from a perfectly natural condition; it had the
same pale; appearance as the skin; no coating, no redness, no development of
the papillae.

From this time to the period of his death varied plans of treatment were
adopted, with a view of relieving the epigastric pain. The trisnitrate of bis-
muth with the pondrous carbonate of magnesia and the muriate of morphia cer-
tainly afforded very marked relief; amongst many remedies that were employed
this was the most efficacious. Benefit was likewise derived from the carbonate
of iron with rhubarb, and a sedative. Small blisters were also used, with a
strong solution of the extract of belladonna applied warm on a piece of flannel
and laid over the epigastrium. Suddenly and without any appreciable cause his
breathing became embarrassed, cough came on, and terminated in the expecto-
ration of muco-purulent matter to the extent of three half-pints daily.

Under the continued irritation of pain, and bronchial disease, my patient sank,
three weeks after the attack of haematemesis, at the age of 52. I believe the
immediate cause of his dfeath to have been bronchitis. I am firmly convinced
that from his stomach disease he would have recovered. — Med. Chirurg. Rev.
October, 1838.

22. On Simple Ulceration of the Stomach, with observations on those forms of gas-
tric irritation which more commonly precede and accompany it. The Medico-Chir-
rurg. Review for October last, contains a very interesting memoir on this sub-
ject by Langston Parker, Esq. The general pathological character of this
disease, Mr. Parker states to be that of a simple round, or oval ulcer, with edges

* This part of the history of the case confirms a remark which I have made in
another part of this paper, and which I find confirmed by the experience of M. Cru-
veilheir, viz, that ulceration of the stomach, after having, by care and judicious treat-
ment, been brought to a state of cicatrization, is exceedingly prone to recur from
slight dietetic errors, or even from strong mental impressions. This physician has
seen a case similar to the one I have recorded, in whicii the disease returned three
times, at intervals of from two to four years.

216

Progress of the Medical Sciences,

generally thickened and elevated, in which the mucous and muscular coats of
the stomach are more or less completely destroyed, and the bottom of the ulcer
is formed by the peritoneal coat of the stomach; or, where the ulcers have healed
by a membrane, the result of the process of cicatrization.

The anatomical characters of the disease consist in a round, oval, or irregular
shaped ulcer, more or less deep, occupying various positions upon the internal
surface of the stomach, more frequently however situated in the cardiac portion,
the greater curvature, or, in the vicinity of the pylorus. The edges of these
ulcerations invariably present considerable thickening, so that, in many in-
stances, they appear, as it were, dug out into the substance of the thickened
adjacent coats.

In ulcers of moderate size, the mucous and muscular coats of the stomach are
commonly destroyed, and the bottom of the ulcer is formed by the peritoneal
coat, sometimes very much thickened, a membranous cicatrix, or the base is
rough, uneven, and fungous, and shows that the process of ulceration is still
going on. M. Cruveilher has, Mr. P. thinks, committed an error, in stating
that these simple ulcers of the stomach are generally single. In a great num-
ber of instances, Mr. P. states they are not only double, but even multiple, and
the use of a moderate glass, or even the naked eye, will show in many in-
stances where a large ulcer seemingly exists alone, that the mucous membrane
is covered with many small spots of ulceration which a superficial examination
might pass over.

One great peculiarity of this species of ulcer is its tendency to cicatrize under
proper medical treatment. In some instances the cicatrices of these ulcers pre-
cisely resemble those of a badly healed burn, and they have likewise the same
tendency, if the ulcer be large and deep, and its edges very much elevated, to
pucker up, and draw together the surrounding parts, so that the stomach is
contracted and deformed, its peristaltic motion impeded or destroyed, and the
process of digestion in this manner rendered laborious and painful.

All the cases of simple ulcer Mr. P. has had an opportunity of examining
after death have presented concomitant marks of inflammation in other parts of
the stomach; these have consisted in general increased vascularity of its mucous
membrane— a punctiform or arborescent redness, general or partial — a congested
and distended state of the veins of the submucous cellular coat, with general or
partial thickening of the other tissues.

The terminations of ulceration of the stomach are four; — in three modes fa-
tally, in one favourably. It may terminate in erosion and perforation of the
stomach; — in one way by the continuance of the ulcerative process, and in ano-
ther by the weight of the food pressing continually upon a thin cicatrix, or the
centre of an ulcer occupying the greater curvature or cardiac portion of the sto-
mach. Simple ulceration of the stomach may terminate secondly in a fatal
ha5matemesis, the process of ulceration, by its continuance, opening a large
venous or arterial trunk. It may in a third way become fatal, and wear out the
patient by the constant and violent pain it occasions, destroying his digestive
powers, impeding nutrition, and producing gradual emaciation, and death.
Fourthly, the ulcer may cicatrize, and the patient become perfectly well, though
even in this mode of termination there are two evils to dread — the recurrence of
the disease from slight exciting causes, and the rupture of the cicatrix from the
pressure of food, or from violent exertion.

The following is the general description of the symptoms of the disease as
given by Mr. Parker: — The first of these symptoms is a fixed, acute pain, occu-
pying the epigastric, or left hypochondriac regions, the centre of the sternum,
or some point on the dorsal portion of the spirie, between the scapulae. This
pain is the symptom “par excellence,” it is that, and generally that only which
attracts the patient’s attention; from it he may be for some hours occasionally
free; but never is so entirely during the day. For many hours out of the
twenty-four, this corroding uneasiness harasses the sufferer, sometimes in the
morning, at others in the evening, sometimes in the intervals of meals, but
generally it succeeds to them, and commences with more violence after the din-

217

Special Pathology and Special Therapeutics,

ner meal, continuing- without abatement till late in the evening, when it com-
monly subsides, and leaves the patient comparatively easy for the night, till
breakfast brings back a return of his sufferings. The seat of this pain is, as I
have just stated, variable. I attended a gentleman for some years with simple
ulceration of the stomach, who always suffered most severely in the centre of
the dorsal portion of the spine, and along the course of the intercostal spaces;
in this patient the epigastric pain was not absent, but in some measure masked
by the greater suffering he experienced in the back and sides. These parts were
very sensible to pressure, and he invariably experienced relief of the gastric
uneasiness, from the application of small relays of leeches over the tender spot
on the spine; this, during the latter months of disease was the only remedy that
afforded any marked relief. This patient died ultimately from violent haemate-
mesis.

In many other instances the pain is confined to the centre of the epigastrium,
which is the chief, and indeed the only seat of suffering.

Although the act of taking food occasions the patient so much uneasiness, the
appetite in many cases of ulceration of the stomach continues good, and in some
instances is morbidly increased.- The remark of patients labouring under this
disease is commonly “ I could eat any thing but dare not.” In certain instances
the appetite is defective. This I think arises most commonly from extensive
concomitant inflammatory action, and where the ulceration is complicated with
other lesions of the mucous membrane.

The tongue is in a great majority of instances clean; in some not the slightest
deviation from the healthy condition can be detected; it is neither redder, nor
less moist than usual, and even when ulceration of the stomach has been accom-
panied by profuse bloody vomiting, we observe the tongue to present that
blanched condition which is common to other organs in this state, and not to
offer that contrast to the external skin which is so remarkable in the advanced
stages of pure chronic gastritis, where the vivid redness of the protruded tongue
presents a striking contrast to the sallow, pallid countenance.

T have, in my work on the stomach, adduced a variety of facts, noticed by
myself, and supported by the corroborative testimony of Louis, and Andral of
the uncertainty of the state of the tongue as indicating any particular pathologic
condition of the stomach. The tongue certainly bears no direct relation to the
kind, or degree of disease existing in the stomach. Dr. Stokes has remarked
that too much attention is, and has been paid to it, with this view, by British
practitioners; whilst Louis says “we should examine the tongue for itself
merely, not to ascertain by it what is the matter with the stomach.” I have
rarely met with a case of simple ulceration of the stomach, where constipation
of the bowels has not been a prominent and most distressing symptom; and one
which is a source of great anxiety both to the patient and his attendants. The
attacks of pain are more violent and frequent whilst constipation is present, and
again there is great difficulty in framing an aperient that will relieve constipa-
tion, without producing great pain during its operation.

Nausea is not a common attendant upon this disease, but sudden and some-
times fatal vomiting of blood, or a black fluid, comes on at an earlier or later
period. M. Cruveilhier considers the black vomiting peculiar to, (and almost
pathognomonic of,) ulcerations of the stomach, to result itself from blood,
slowly secreted from an ulcerated surface, and rendered black by its sojourn for
a longer or shorter space of time in the cavity of the stomach, and its mixture
with the acids of the gastric juice.

Bloody vomiting, in ulceration of the stomach, is by far the most dangerous
symptom we have to contend with. I have certainly seen a patient recover
from ulceration of the stomach after several attacks of severe haematemesis;
these cases, are, however, comparatively rare. Discharges of blood rarely occur
early in the disease, and when they come on to any extent, a patient is worn
out and emaciated by constant pain; they are very commonly fatal. I have
more than once seen persons, with ulceration of the stomach, die in the very act
of throwing up blood.

No. XLVIL— May, 1839.

318

Progress of the Medical Sciences,

Before any vomiting of blood, or black fluid, takes place in ulceration of the
stomach, it will very often be found that these matters are passed by stool.
The blood is slowly exhaled, mixes with, and colours the food and faecal matter,
and passes off in stools as black as pitch. This symptom, considered with
others, will leave no doubt on the mind that blood is slowly oozing from an
ulcerated surface; and it will lead to the adoption of measures to prevent the
sudden vomiting of blood, which commonly succeeds to the black discharges
by stool, of which these latter are, in many instances, premonitory symptoms.

The manual examination of the epigastric region contributes little to confirm
our diagnosis in this disease. It is sometimes highly sensible to pressure, at
others perfectly indolent. In the advanced stages of disease in the male, where
the coats of the stomach are commonly thickened, a tumour may be detected,
but, apart from the existence of other symptoms, we cannot say whether this
tumour result from mere thickening, the result of chronic gastritis, or whether
this thickening be accompanied by ulceration or cancer.

The general appearance of patients suffering from ulceration of the stomach,
is haggard and anxious in the extreme. Defective nutrition has produced a
paleness in their tissues which is very remarkable; the conjunctiva has some-
times the appearance of the whitest marble, and the whole aspect of the patient,
in the advanced stages of disease, even when haematemesis has not taken place,
is that of a person blanched by repeated haemorrhages.

We must here inquire into the nature of those symptoms of gastric irritation
which precede the actual state of ulceration, in other words, we must look for
the causes of this disease; these, I believe, will be found in certain states of gas-
tric irritation, which are very much under the control of medical treatment.

M. Cruveilhier says, “ The history of the causes of simple ulcer of the sto-
mach is involved in deep obscurity; or, rather, this disease recognises all the
causes of gastritis for which it has been mistaken. But why is only one single
spot of the stomach affected, whilst all the other parts of the stomach are in a
healthy state!” It is singular so accurate a pathologist as M. Cruveilhier
should have made a statement disproved even by many of his own cases, by the
remarkable one detailed in this paper, and by the pathology of the stomach
generally. The simple ulcer is met with as frequently double, triple, or multi-
ple, as it is single; and I have never seen a case where this organ has not pre-
sented the most unequivocal signs of long continued inflammatory action, most
frequently marked by general or partial thickening of its coats. Not only are
the consequences of inflammation to be found in the stomach after death from
ulceration, but the whole class of symptoms, which precede and accompany ul-
ceration during life, are clearly dependent upon inflammation, as the results of
inflammation sufficiently prove.

Ulceration of the stomach succeeds more particularly to two conditions of
gastric irritation, which it is important here to notice; these are inflammatory
indigestion, or certain forms of gastritis in males, and those affections of the
stomach which occur in females whose menstruation is irregular, who are the
subjects of hysteria, or who are confirmedly chlorotic. These forms of irritation
are clearly of the inflammatory kind, though essentially modified by the state of
the economy in which they occur.

I shall endeavour to give a brief account of such of these forms of gastric irri-
tation which I have seen terminate in fatal ulceration of the stomach. The case
detailed in the earlier part of this paper,* will illustrate in its history, the origin
and progress of that form of indigestion which is evidently of an inflammatory
character. The fresh attacks of this disease are generally marked by fulness
after meals, distention of the stomach, eructations, heart-burn, nausea, pains in
the back and sides, uneasiness in the epigastrium, terminating in fixed and con-
stant pain, aggravated by taking food; strong beating of the heart, throbbing of
the carotids, head-ache or stupor succeeding a meal.

it is true that in a vast number of instances the inflammatory forms of gastric

* Sec preceding article.

219

Special Pathology and Special Therapeutics.

irritation never terminate in ulceration of the mucous membrane of the stomach,
though I believe, from some experience in this class of diseases, that ulceration
is a more frequent termination of them than is generally supposed. This opin-
ion is likewise corroborated by the experience of M. Cruveilhier, who, in his
second paper on this subject, states this disease to be much more frequent than
he had at first supposed.

I have seen the inflammatory form of indigestion, which is a true partial gas-i
tritis, terminate in ulceration in five months, from its first commencement, in a
patient w'ho had never, previous to this period, suffered in the most remote
degree from any affection of his stomach.

M. Cruveilhier believes in the existence of acute ulceration of the stomach,
and adduces the case of a patient who died from the disease, twelve months
after a slight attack of cholera, prior to which he had been in perfect health. He
mentions a second case terminating fatally in ten days from perforation, the sub-
ject of it never having been ill before this period, the anatomical characters of
the disease showing it to be a recent ulcer. A third case is mentioned succeed-
ing to indigestion of some months standing, fatal by perforation.

The most insidious and alarming forms of irritation in the stomach, if we
regard their occasional termination, are those painful affections, and disordered
conditions of the digestive powers which occur in young females, particularly
where there is any disorder in the functions of the uterus. It will be found on
examination that most patients who are chlorotic suffer more or less from some
form of irritation in the stomach or bow'els.

Some complain of pain after food, nausea, daily vomiting, diarrhoea, loss of
appetite with heat and tenderness in the epigastrium. Accompanying these
symptoms there is commonly a dry, red tongue, and the patient sufers from a
most distressing weakness.

Not unfrequently, in the midst of these symptoms, or after some partial
degree of amendment, the patient is seized with acute pain in the bowels, and
suddenly sinks and dies. On examination the stomach is found perforated in
the centre from ulcer, with thickened and elevated edges, the immediate vicinity
of which exhibits marks of inflammation and thickening of the coats of the
stomach, whilst the remainder are generally very thin, and the mucous mem-
brane in all other joints presents a remarkable pallor or whiteness, and is almost
exsanguined; — a totally different condition from that observed in the mucous
membrane of patients dying from that ulceration of the stomach which is the
result of general inflammatory indigestion or pure chronic gastritis. In the
former instance the disease is generally confined to a very small portion of the
mucous membrane; it is a localised inflammatory action occurring in a constitu-
tion in an extreme degree of w^eakness or irritability, and seated in tissues so
badly nourished that they present but little resistance to the fatal termination of
the disease in perforation of the coats of the stomach.

I conceive the difference of the circumstances, under which the disease we are
now considering occurs (in the male as the result of inflammatory indigestion,
on the one hand, and in the chlorotic, or hysteric, or debilitated female already
exhausted by uterine irritation, on the other,) to be one most powerful cause
why the disease so much more frequently terminates in perforation in the latter
than in the former.

I know of no instance where cicatrization of an ulcer of the stomach has been
shown to have taken place in the female. In the male, the case of Professor
Bedard will suggest itself to the minds of all, whilst the case now detailed is
another and perhaps the most remarkable hitherto recorded. Cruveilhier states
that the simple chronic ulcer has a tendency to cicatrize, and Dr. Abercrombie
says that he is satisfied that he has seen the cicatrices of such ulcers when the
patient has died of another disease, after having been for a considerable time free
' from uneasiness in the bowels. The latter authority however records nothing
definite upon the subject.

I believe ulceration of the stomach to be more frequent in the male than in
the female, whilst the fatal termination of this disease by perforation is much

220

Progress of the Medical Sciences,

more frequent on the part of the female than the male. Mr. Pritchard of
Leamington, in a pamphlet on the organic character of hysteria, has collected
from various authorities eighteen cases of perforating ulcer in the female, whilst
he has only been able to meet with eight recorded ones of the same disease in
the male.

It is true that the disease is more frequently verified after death in the female
than in the male, but I think it will be found that the disease is more prone to
cicatrization in the male from the circumstances I have mentioned, and again in
the male its fatal terminations are more frequently by haematemesis, and gradual
exhaustion, than by perforation, from the simple circumstance that the coats of
the stomach generally, or those merely in the immediate vicinity of the ulcer
are most commonly the seat of considerable thickening the consequence of long
continued chronic inflammation. We do not observe the same causes in the
female.

The treatment of ulceration of the stomach must be modified to suit the par-
ticular kind of affection we are called upon to manage, and hence it must be
considerably different in the male, where the disease is the result of gastritis or
inflammatory indigestion in any of its numerous forms, and in the female where
it occurs in the midst of disorder of the health generally, and upon which, in
such instances, I have no doubt it very materially depends.

I shall not here notice any plan of treatment adapted to the forms of inflam-
matory indigestion, having said enough on this subject in my previous work.

The grand indication in the treatment of ulceration of the stomach is to bring
about cicatrization of the ulcer, and this I believe will be best accomplished in
the following manner, at least it is the mode I have generally found most
successful.

The patient must be limited to the smallest possible quantity of food under
which he can be tolerably comfortable, but the wants of the stomach on this
head must be satisfied, for if any degree of craving, or irritability be induced by
the abstinence, it is carried too far. It must have been noticed by all that have
had the care of patients with ulceration that they are tolerably easy except after
a meal. They should never be suffered to take meals, properly so called; we
should first attempt to discover what kind of food they are most easy under, and
small quantities of this should then be taken every two hours, so as to prevent
the appetite ever experiencing the sense of hunger, or ever feeling a desire to
satisfy it by eating a tolerably hearty meal. It is almost impossible to lay
down any rules as to the kind of food under which a patient with ulceration will
be most comfortable^ it very commonly happens that light animal food agrees
better than a farinaceous diet, and I have occasionally found cold weak brandy
and water in such instances the best sedative. The stomach must never be dis-
tended by food, nor any kind of food administered which so far disturbs the
digestive powers, as to give rise to the evolution of much gas during digestion,
which in itself, is nearly as great an evil as distending the stomach by food.
The next point is the condition of the epigastrium, if there be tenderness on
pressure, or heat in this situation, leeches must be applied in quantities suited
to the powers of the patient till it is removed. Even in the advanced stages of
disease, local bleeding from this is highly serviceable; it diminishes congestion,
and renders the attacks of pain less frequent and violent. Employed after at-
tacks of pain it relieves that venous distention occasioned by them, which fre-
quently terminates in haematemesis. When the stools are black, or bloody, it
is highly useful, frequently changing their character by diminishing the con-
gestion or inflammation in the stomach, and checking the exhalation of blood
from the ulcerated surface. Haematemesis frequently relieves all the symptoms
of ulceration, sometimes for weeks; but we must recollect a patient may die,
and commonly does die during the attack; these efforts of nature therefore should
he imitated by the employment of means likely to bring about the same result.
If the epigastrium be indolent, and the stools natural, or nearly so, the next
remedy of importance is counter-irritation, by blisters, the antimonium tartariza-
tum, or other remedies; this should be persevered in constantly, and unceasingly

221

Special Pathology and Special Therapeutics,

as long as disease remains. I do not think setons productive of much good. I
have seen them useless where repeated blistering has afforded great relief. Fo-
mentations laid on the epigastrium and kept on for several hours, sponging this
region night and morning with very hot water, reposing in a tepid bath for a
considerable time daily, are all remedies that may be employed with advantage.
The patient is always worse during constipation; the bowels are best regulated
by enemata. If aperients be given they should be of the very mildest character;
a few grains of rhubarb with a tenth or twelfth of the muriate of morphia — the
ponderous carbonate of magnesia prepared by Henry or Howard, administered
in some infusion of orange-peel, or mint tea, are remedies sufficiently active; the
common magnesia is worse than useless. After cicatrization has even taken
place all active purgatives should be avoided. M. Cruveilhier records a case
of rupture of a cicatrix from violent aperients administered to relieve an apoplexy.
The violent peristaltic action of the stomach induced by the aperient had rup-
tured the cicatrix of an ulcer. Internal remedies are exhibited in ulceration of
the stomach with several objects. To relieve pain, to facilitate cicatrization,
to check the oozing of blood from an ulcerated surface, or lastly to remedy some
general constitutional weakness or irritability which appears unfavourable to
the healing of the ulcer.

To answer the two first indications minute doses of morphia may be adminis-
tered with the trisnitrate of bismuth. The nitrate of silver, first proposed by
Dr. James Johnson, will be found very serviceable with this view. The sul-
phate of iron also may be employed; there is sometimes a sponginess of texture
in the mucous membrane in long continued cases of ulceration when these latter
remedies are highly beneficial. There is occasionally also a great degree of de-
bility, of languor, of laxity of tissue accompanying ulcer of the stomach, in
which the exhibition of tonics becomes necessary, and in such forms of disease
the carbonate of iron, or even the mistura ferri. comp, are employed with great
benefit. Every thing that affects the constitution generally has an effect upon
the healing of the ulcer, and hence the condition of the health generally demands
our strictest watchfulness; the functions of the skin; the state of the bowels; the
urine; the epigastric region all demand unceasing attention. I would impress
upon the reader that ulcers of the stomach commonly cicatrize, as the state of
the general health under which they first made their appearance improves. It
is true that they more immediately depend upon the pathological condition of
the stomach, but this is most commonly the result of general constitutional
causes.

The great difference which exists between the treatment of ulcer of the sto-
mach in the female and in the male, depends chiefly upon the general condition
of the economy in which the diseases separately occur, and the pathologic cha-
I'acter thus induced in the stomach in which the disease is seated. — Ibid.

23. Experiments on the application of narcotics in the form of vapour. — By C.
W. Hufeland, of Berlin. These experiments were made with hyosciamus,
belladonna and opium. The number of cases given is twelve, of which the first
occurred in a servant girl 18 years of age, attacked with epilepsy, the result ap-
parently of impeded menstruation. The first employment of the bath had the
effect of inducing a paroxysm. The second was attended with more favourable
effects; and the daily repetition of the remedy for two months, removed all dis-
position to the convulsive attack, and left the patient in a state of comparative
comfort, interrupted only by occasional paroxysms of pain in the neck and breast.

The second case was also epilepsy, occurring in a young woman of 20, and
which had commenced a year and a half before, in consequence of a fall in the
water. After a period of apparent remission, the fits returned with increased
violence; and from the 16th of July to the 1st of August, the number of attacks
was not less than five. From this time the patient was subjected to the daily
use of the narcotic vapour bath for 15 minutes, and at the end of 84 days from
the commencement of this course, had had no attack of the complaint.

A merchant’s clerk, 17 years of age, of feeble constitution, had been affected

19*

222

Progress of the Medical Sciences,

U'ith epilepsy one yenr, in conjunction with nervous fever. The narcotic vapour
was tried upon him without advantage.

A young woman of 18 had difficult menstruation, followed by epilepsy and
intermittent bronchitis. After several remedies had failed, the narcotic vapour
was tried. Each trial brought on a new fit, and was followed by severe pain in
abdomen. The remedy was abandoned.

A servant girl, 26 years old, wms attacked with epilepsy, after chill and de-
pression of mind. Having suffered under it for six months, she was for three
months more subjected to ordinary treatment, but in vain. The narcotic vapour
was then tried, but caused much inconvenience, and no benefit.

A servant girl, 20 years old, had been one year subject to epilepsy, the origin
of the affection being unknown. After being subjected to other treatment, she
was placed in the narcotic bath. The fits, which had recurred three or four
times a month, were, after four weeks use of the remedy, suspended for 23 days.

A female servant, 19 years old, previously healthy and of plethoric constitution,
was attacked with epilepsy after severe chill. The opiate bath was applied,
and for two months she enjoyed an immunity from the disease.

A married woman, 29 years old, had had epilepsy for eight years, that is,
since the period of her first labour, the disease was complicated with chorea, and
the intellect greatly impaired. The use of the narcotic vapour produced violent
paroxysms, and could not therefore be persevered in.

H. A., 16 years old, had suffered from epilepsy since his tenth year. The
narcotic vapour was tried, but produced not the smallest effect.

A shoemaker’s apprentice, 27 years old, had suffered much from abdominal
affections, from which he was relieved by the performance of active military
service from 1813 to 1815. A violent exertion brought on hemoptysis, which
was followed by epilepsy. He entered the hospital the 17th of September, 1818.
After various other remedies had failed, the narcotic vapour was tried. During
fifty-two days from the commencement of its use there were two fits; the next
thirty-eight days passed without any, and then a slight one followed.

A girl 18 years of age, who had never menstruated, had had epilepsy seven
years, which was attributed to a fright. She became idiotic. Among various
remedies, the narcotic vapour was tried, but without advantage,

A bookbinder’s apprentice, 20 years old, well formed, reported, on his admis-
sion to the hospital, that he had an attack of epilepsy fourteen days previous
after a chill. The attacks continued after his entrance with great severity. The
employment of the bath suspended them for two months in the outset, and its
persevering use cured the disease. — Aewe Auswakl kkiner medizinischer Schriften,

24. Heart diseases not seated in the heart. — Hufeland thinks that since atten-
tion has been directed to the diseases of the heart by Corvisart, Testa, Kreysig,
and others, practitioners have been disposed to admit too readily the existence
of organic disease of this organ. He thinks that in the great proportion of cases
where the heart appears to be affected primarily, the disturbance is of a general
character, and with its cessation, the anomalous symptoms exhibited by the heart
cease also. The following are the sympathetic heart affections, which have
come most frequently uuder his observation.

I. Sanguineous congestion. One of the most frequent causes of disturbance
of the functions of the heart, is the tendency to hemorrhoidal congestion. In
some cases the disturbance is occasioned by the interruption of the hemorrhoidal
flux; in others, it is the effort of nature to bring about the discharge, by which
the circulation is rendered more active. If then the force of the blood be thrown
upon the lungs, asthma, haemoptysis or pneumonia may ensue; if on the heart,
some undue action of this organ is developed, such as without careful attention
to the etiology of the case, might be supposed to be idiopathic. In such- cases
the best cure of the heart disease, is to apply leeches to the anus, to use cooling
diet, cold water in abundance, moderate exercise and laxatives.

A man 40 years of age, of tolerably robust constitution, who had had bleeding,
and afterwards dry piles, and with whom both had recently disappeared, began

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1 0 exhibit symptoms of heart disease, which now, for a year, had reached a de-
gree of intensity which excited suspicion of organic change: the more as his occu-
pation required strong muscular exertion. His heart beat constantly with vio-
lence, his breath was obstructed; with every motion the difficulty increased, the
pulse was irregular; he had attacks of vertigo, and was unable to lie upon his
left side. After trying various remedies to little purpose, he came to Dr. Hufe-
land. Doctor H. recogni-ed it as a case of obstructed hemorrhoids, directed
leeches to the anus, mustard pediluvia and cathartics. Under this treatment
the disease gradually yielded, and, at the end of four weeks, he was fully re-
stored.

A man 50 years of age, of tolerably robust constitution, who had often suf-
fered from affections of the liver, and from hemorrhoids, was seized with palpi-
tation, which at length became constant, and attained such a degree of intensity
that it impaired his respiration, caused vertigo and great anxiety, and was so
oppressive in lying, as to deprive him of sleep for whole nights. At length the
ribs of the left side were evidently protruded, so that no doubt seemed to remain
of the actual enlargement of the organ. Blood letting, digitalis, and cold appli-
cations to the surface, afforded only partial relief. At length the plan was tried
of leeches to the anus and aloetic purging, and under this treatment the patient
recovered.

2. Nervous or adynamic heart disease* It is matter of familiar observation
that palpitation, anxiety, irregular pulse, belong to the common signs of hypo-
chondria and hysteria; and they may attain such a degree of severity and con-
stancy as, by the inexperienced, to be readily mistaken for idiopathic and organic
heart disease. If under this supposition they are treated with blood letting and
reducing remedies, the intensity of the symptoms is inevitably aggravated.
Every bleeding increases the palpitation and the anxiety, and this circumstance
in connection with the pale urine, the tendency to melancholy, and the more or
less periodical character of the attacks, must suffice to open the eyes of the judi-
cious practitioner to the true nature of the affection.

3. Sympathy and antipathy with other organs have a marked influence on the
functions of the heart. Especially may this influence be remarked as exerted
by the abdominal organs. The ancients regarded the intermittent pulse as an
abdominal pulse, no doubt having observed that it is symptomatic of affections
below the diaphragm. Flatulence, by distending the abdomen and diminishing
the capacity of the chest, is a frequent cause of disturbance of the functions of
the lungs and heart.

Enlargement of the liver exerts an important influence on the functions of the
heart. Brera regards it as the most frequent cause of heart diseases. Mental
affections again have a most important and familiar influence on affections of this
organ. Individuals have suffered for years with apparent disease of the heart,
simply from being placed under the influence of strong mental excitement, the
disappearance of which was followed by the complete relief of every preceding
symptom.

4. Metastatic heart disease. The transfer of various imflammatory diseases,
particularly rheumatism and gout, from their previous seats to the chest, and the
production in this way of severe affections of the heart, has been matter of
familiar observation, particularly with English and German practitioners. Dr.
H. has seen numerous cases in which the patients were suddenly relieved from
gout or rheumatism to be as suddenly the victims of affections of the heart.
These affections rarely pass from a functional to assume an organic character.
The functions of the organ continue to be disturbed for a greater or less period,
but it is only in cases where these derangments are unusually prostrated, that
any serious affection of the organ follows.

A boy, 14 years of age, was attacked with severe palpitation, accompanied
with dyspnoea and some protrusion of the ribs df the left side. On inquiry, it
appeared that he had been affected severely two years before with scabies. Which
had disappeared under the use of external application. Sulphur, digitalis and
calomel were now ordered internally, a blister was placed on the region of the

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Progress of the Medical Sciences,

heart, a cataplasm of mezereon bark applied to the left arm, and thus a purulent
discharge kept up from both surfaces. By these means a visible amendment
was produced at the end of fourteen days, and, in six weeks, the cure was com-
plete.

Thus far our author. It is scarcely necessary to add, that the improvements
in the physical exploration of the chest, a subject which had excited little atten-
tion in Germany at the time this essay was written, have removed many of the
sources of doubt and uncertainty which have heretofore existed, and made it far
more easy to avoid the error of confounding functional with structural disease.
Caution, however, is still needed, and the suggestions of Dr. H., if neither very
novel or profound, will yet be acknowledged to be the result of careful observa-
tion, and to deserve for their honesty of purpose the respect of the profession. —
Ibid,

SURGERY.

25. Encysted Dropsy of the Thyroid Gland. — Upwards of twenty years ago Pro-
fessor Maunoir of Geneva described a disease bearing a great resemblance to
bronchocele to which he gave the name of hydrocele of the neck; and he recom-
mended for its cure the puncturing of the tumour, and after evacuating its con-
tents, the insertion of a seton through it. Three cases are related in which these
means of treatment were successful. (See this Journal for Feb. 1836 p. 507.)

In a paper on the treatment of hydrocele in St. Thomas’s Hospital Reports,
(Nov. 1835) Mr. Green extols the efficacy of the seton in the disease we are
noticing. (See this Journal for Aug. 1836, p. 521.)

Da. Selwyn of Cheltenham in a memoir in the Lancet (15 Dec. 1838) states
that he has treated “ at least a dozen cases with invariable success” by means
of the seton.

Dr. Selwyn’s claims to the discovery of the existence of such a disease as en-
cysted dropsy of the thyroid gland and of originality in his method of treating
it we need not discuss, after what we have already said. His testimony to the
value of the seton as a means of cure is however worthy of being recorded.

26. Division of the Prostate in Lithotomy. — H. M. Phillips, Esq. Assistant
surgeon to the Royal Cornwall Infirmary, strenuously recommends the following
modification of the above operation, as diminishing the risk of life usually at-
tending the lateral operation of lithotomy; viz. — hemorrhage, puncture of the
rectum, peritoneal inflammation, with purulent deposit about the neck of the
bladder; and infiltration with its consequences.

“ Having introduced a straight grooved staflf into the bladder, and having reach-
ed the membranous portion of the urethra by the usual incisions on the left side
of the perineum, I cut into the groove of the staff. The staff being still firmly
held by an assistant, I introduce the nail of the fore finger of the left hand into
the groove, then insert the point of the knife, also into the groove in advance of
the finger, its flat surface resting on and parallel to the plane of the nail; both
are then carried steadily onward until the knife enters the bladder, indicated by
the gush of water; it is then withdrawn, and the finger alone is pushed firmly
and fairly into the bladder. The forceps is then introduced upon the finger (the
best director in all operations), and the stone is embraced.

“ It will be seen that the principle acted upon here is the same as that which
proved so successful in the hands of Cheselden, and was so warmly commend-
ed by Sir Astley Cooper; namely, the partial separation of the upper from the
lower portion of the prostate gland with the knife, completing the separation to
the necessary extent without a cutting instrument. Cheselden used for this pur-
pose the bluntcurved gorget, I use the finger. And I do declare, having tried
this method on the adult, 1 have found no difficulty whatever in enlarging the
opening sufficiently, by simply protruding the finger into the bladder, which is
accompanied with the sensation of a slight tearing.

225

Surgery,

“The advantag-es of this mode of operating are — the certainty of avoiding
hsemorrhage, or of puncturing the rectum, and the equal certainty of being able
to make the opening into the bladder large enough, to extract the stone, and no
larger. I may add, that I never yet found any perineum too deep to prevent my
enlarging the section of the prostate with the finger; and I am quite satisfied
that any lithotomist who may adopt this method will not readily abandon it.
— London Med. Gaz. 15 Dec. 1838.

27. FearrCs case of Aneurism of the Innominata, treated hy ligature of the Carotid
and Sub-clavian arteries. — The Lancet^ of 15th Dec. 1838, contains the termina-
tion of this case, of which the early history was given in our Nos. for Feb.
1837, (p. 522) and Feb. 1839, (p. 498). The patient died after ten days illness,
of pleuritis, Nov. 27th, 1838.

Mr. Fearn states, that the necropsy disclosed the following appearances :
“ The whole surface of the body was of an intense yellow colour, indicating at
once the existence of jaundice i there was much subcutaneous fat. On opening
the chest, the lungs did not collapse ; this was owing, chiefly, to recent pleuritic
adhesions on the right side, and to adhesions of longer standing on the left ; the
left lung w'as crepitant and healthy ; the pleural membrane covering the middle
lobe, and the lower and posterior surfaces of the upper lobe of the right lung,
W'as larded over with recent lymph, and the membrane was also red and vascu-
lar; the corresponding portions of lung were solid, exuding a bloody fluid of a
muco-purulent character, and presented an example of the red hepatisation.
The lining membrane of the windpipe and larger bronchial tubes was healthy in
appearance ; there was no water in the pericardium or pleural cavities. The
heart was very unusually fat for the age of the patient (30 years); its valves,
both auriculo-ventricular and semilunar, were healthy ; the inner surface of the
whole of the arch of the aorta was studded with small cartilaginous and ossific
patches. The innominata alone was the seat of the aneurismal disease ; it pre-
sented a globular tumour, an inch and a half in diameter, pressing upon the
front and right lateral portion of the trachea, about an inch above its bifurcation,
so as to lessen its diameter about one-third ; this tumour, with the exception of
a channel of the usual calibre of the innominata, W'as completely filled with a
dense, organized, light-coloured fibrinous coagulum. The coats of the diseased
artery had given way on their external and posterior wall ; the right common
carotid was permeable for about a third of an inch from its origin, and opposite
the lower margin of the cricoid cartilage there was an interruption to its conti-
nuity where the ligature bad been applied in the first operation. The separated
portions of the vessel, which were distant from each other the fourth of an inch,
were connected merel}^ by cellular membrane ; the upper portion of the vessel
was impermeable to where the external carotid was given off; the right side of
the thyroid gland was much larger than the left, owing, probably, to its increased
nutrition from the enlargement of the inferior thyroid artery, in carrying on the
collateral circulation; the subclavian artery was healthy; the branches of the
thyroid axis were considerably enlarged ; the main trunk was severed just at
the external margin of the anterior scalenus, in the same way as the carotid. In
the abdomen we found the liver harder than usual, and of a lighter colour; the
gall-bladder was very much distended with bile ; the stomach and intestines
healthy ; the kidneys presented an example of Bright’s disease ; they had a
mottled appearance, showed much fat when cut through, and the secreting por-
tions of the organs were almost entirely absorbed, the tubuli extending to their
surface. There were numerous extravasated spots of blood upon the lining
membrane of the pelvis of each kidney ; there was nothing else worthy of obser-
vation.

“If we take into review the whole of the circumstances of the* interesting
case which has thus terminated, we cannot but arrive at the conclusion, as I
observed in my last communication upon it, that the steps which were adopted
for the relief of the patient were the means of saving her from an otherwise
inevitable death ; and we may further affirm, taking into account the post-mortem

226

Progress of the Medical Sciences.

appearances above recorded, that the distal operation for aneurism of a vessel
so near to the heart even as the innominata, is abundantly sulRcient for its cure.
It is quite true, that in this case a considerable tumour remained after the opera-
tion, but the previously existing sac was so completely blocked up with the
dense coagulum which Nature had employed for the cure, that there was no
longer any risk of death from its rupture. Had the patient escaped the casualty
which led to her death, and lived but a few years longer, it is more than pro-
bable, looking to what occurs in aneurisms seated externally to the great
cavities, where a ligature has been employed, that the tumour, in this instance,
would have disappeared entirely. I saw a case, a few years back, of aneurism
at the bend of the arm, produced by bleeding, which was treated by ligature of
the brachial artery ; the tumour, at the time of the operation, was as large as a
man’s fist ; but though the progress of the disease was arrested by the operation,
two years elapsed before the swelling was entirely dissipated. All this is
owing, no doubt, to the imperfect state of organization of the mass of coagulum,
and to the almost total absence of absorbent vessels.

“ It may not be amiss to mention, that the patient lived two years and three
months after the ligature of the carotid, and sixteen weeks and five days after
the subclavian had been tied.”

28. On the cure of wry neck hy dividing the sterno-cleido-mastoid muscle beneath
the skin. — By Prof. Dieffenbach of Berlin. The cure of wry neck, by dividing
the sterno-cleido-mastoid muscle beneath the skin, is the ingenious invention of
Dupuytren. Eight years ago I communicated some favourable results of my expe-
rience in this operation in “ Rust’s Surgical CyclopEedia,” Vol. III., page 623, in
the article Caput Ohstipum., and since that period I have had many opportunities of
repeating it, more especially since Stromeyer, by his admirable operation on
club-feet, directed our attention to the division of other contracted tendons and
muscles. The advantages of this mode of operation by a small punctured
wound, consist in obtaining a quick and durable cure, and in avoiding an ugly
cicatrix, which generally produces new contractions. The former method which,
consisted in exposing the lower part of the contracted muscle, making an inci-
sion through the integuments and dividing the muscle on a director, requires a
long after-treatment. In this case the cicatrix uniting the ends of the muscle
adheres to the cicatrix of the skin, and an obliquity in a higher and much less
curable degree takes place. In the old operation it sometimes happened that
the pus found its way to the anterior mediastinum, or the whole cellular tissue
of the neck sphacelated, and a relapse of the contraction, or death followed.
The new operation of Dupuytren was at first received with enthusiasm, and
everywhere adopted. It is remarkable, however, that in France it was nearly
forgotten until very lately revived by Guerin, Bouvier, and Duval.

The instrument which I use in this operation is a very narrow falsiform knife.
The patient is placed in a chair; one assistant draws the head to the opposite
side, and another depresses the shoulder of the affected side; by this means the
muscle is rendered more prominent. 1 now pinch up the skin and muscle, with
the thumb and index-finger of my left hand, and insert the knife, under the mus-
cle, then turn the edge of the knife towards the muscle, until the point reaches
the skin on the opposite side, which, however, is not pierced. While drawing
out the knife, pressure by the thumb of the same hand is employed, and the mus-
cle is divided. At the moment of the division a dull, soft, cracking noise is
generally heard, produced by resonance of the thorax, and sometimes this noise
is very loud. The best place to insert the knife is in the triangular space be-
tween both portions of the muscle, half an inch above their insertions. If ope-
rating on the left side I divide from this point the anterior portion, and then, in
an opposite direction, the posterior one. At the right side I introduce the knife
between the trachea and the anterior portion of the muscle, and after having di-
vided the latter, I cut the posterior part if required. At the moment of drawing
back the knife through the punctured wound I quickly press with the thumb
upon the spot to prevent an extravasation of blood beneath the skin; I cover it

Surgery. 227

with a solid dossil of lint and straps of adhesive plaster, and then apply a ban-
dage. Two neckhandkerchiefs serve to support the head in the former oblique
direction, without straightening it. This is done partly to prevent a collection
of blood, and partly to promote the union of the divided muscle. The patient
is ordered to keep quiet, in a horizontal position in bed, and to take a mild anti-
phlogistic diet.

In most cases the wound heals very quickly. At the place of a divided mus-
cle a swelling is commonly found; sometimes a fluctuation is felt, owing to a
collection of blood. In the latter case the plasters are again applied more firm-
ly, to accelerate the absorption, and this has soon the desired effect. Lukewarm
lotions, and frictions with warm oil, are sufficient to cause the absorption of any
tumefaction which may remain. If suppuration takes place, the pus should be
evacuated by an incision and simple dressing applied. The following cases,
however, will show how rarely this is met with.

In my first cases, and in those in which the vertebrae of the neck were very
much displaced laterally, in consequence of the muscular contraction, I used to
extend the neck gently some weeks after the operation upon the extending bed,
or with Glisson’s swing, in a sitting posture. More recently, however, 1 con-
fined myself almost exclusively to a collar half the breadth of the neck, made
of pasteboard enveloped in thick cloth, which forced the patient to bend the neck
to the opposite side. I found the latter of more use than violent extension,
which only inclines the muscle to react, makes it tender, and therefore must be
removed, in consequence of which the head again inclines to the affected side.

I will now detail some cases in which the operation was performed with the
best results: —

Case 1. — Charles Meir, tailor, 24 years old, suffered from a shortening of the
right sterno-cleido-mastoid muscle. From his thirteenth year he wore an iron
instrument, but the obliquity of the neck increased, and he was obliged to leave
it off. I divided both insertions of the muscle at separate times. I supported
the bandage above-mentioned by a spica humeri. No extravasation of blood
nor suppuration followed. The patient was confined ten days' to bed, and I
afterwards exttmded the neck gently for a time. The cure was completed in
three weeks, and the patient’s neck became perfectly straight.

Case 2.— The son of the Councillor Dorn, five years old, was born with a
shortening of the right sterno-cleido-mastoid muscle. Machines had been ap-
plied without any benefit. I divided both origins of the muscle. The hemor-
rhage from the wound was so profuse that the patient fainted. I used the same
bandage; there was no extravasation of blood, no suppuration, and the cure was
complete at the end of the third week.

Case 3. — A relation of the above-named boy, living in the same family, eigh-
teen years old and tall, was also afflicted with a considerable shortening of the
right sterno-cleido-mastoid muscle, so that the head could only be moved from
the right shoulder to the extent of half a hand’s breadth. The division of both
heads of the muscle occasioned a very loud cracking noise, partly arising from
the strong extension, partly from the meagreness of the young man. Scarcely
a drop of blood was shed; the wound healed in a few days, and in four weeks
the young man was perfectly cured.

Case 4. — A. Kopfer, of Frankfurt, six years old, afflicted with contraction of
the right sterno-cleido-mastoid muscle, had been treated with machines two years
without success. I divided the muscle. The wound healed in three days.
Eight days after the operation the child was sent home perfectly straight.

Case — F. Striech, a stout boy, ten years old, had a strong contraction of
the right sterno-cleido-mastoid muscle. The whole muscle projected like a hard,
tendinous ligament, and the head was very oblique. The divided parts separated
wdth a loud cracking noise. The wound closed in a few days, and the patient
was cured by the use of a swing, and by a bandage round the neck.

Case 6. — The Baroness de Schalten, eleven years old, afflicted with contrac-
tion of the right sterno-cleido-mastoid muscle, had for along time tried gymnas-
tics, but had not used a machine. I divided both portions of the muscle: the

228

Progress of the Medical Sciences,

liidy was kept quiet during eight days; afterwards the ordinary bandage was
applied, and she was perfectly straight at the end of the third week.

Case 7. — F. P. Pietish, three years old, affected with shortening of the ante-
rior portion only, was perfectly cured in five days. In this case it was not even
necessary to employ a bandage.

Case 8. — The daughter of a servant of Mrs. Scholz, five years old, w^as born
with a strong contraction of the right sterno-cleido-mastoid muscle. The treat-
ment did not differ from that already described, and the cure v^as perfect in the
second week.

Case 9. — C. Schmidt, five years old, suffered from a strong contraction of the
sternal portion of the right sterno-mastoid muscle. He was discharged nine
days after the operation perfectly cured.

Case 10. — Mr. Eben, nephew of the private Councillor Bethe, at Berlin, was
born w'ith a shortening of the right sterno-cleido-mastoid muscle, and in his
twenty-second year was much disfigured by a great degree of obliquity. I
divided both portions of the muscle. The noise produced was so loud, that I
was startled. In three weeks the cure was complete, and the young man per-
fectly straight.

Case 11. — C. Sponholz, from Saxony, ten years old, was affected with a strong
contraction of the right sterno-cleido-mastoid muscle, by which the head was
closely approximated to the shoulder, and at the same time displaced towards
the vertebral column. This boy was discharged perfectly cured, bn the twelfth
day after the operation.

Case 12. — Augusta Lienig, fifteen years old, distorted, meagre, scrofulous,
with a contraction of the right sterno-cleido-mastoid muscle like a fork. I di-
vided them from one point. A fortnight afterwards the girl was perfectly
straight.

Case 13 — was that of a boy six years old, the son of a carpenter, with a con-
traction of the right sterno-cleido-mastoid muscle. The anterior portion only of
the muscle was divided, and by this means the obliquity was removed. The
bandage employed was the common one; the child was confined to bed during
eight days; two days afterwards the cure was complete.

Case 14. — Maria Schoenig, an amiable girl, eleven years old, affected with a
congenital contraction of the right sterno-cleido-mastoideus, affecting, however,
only the posterior portion of the muscle, was perfectly cured by division in
twelve days. The dressing was the common one, and, as in the foregoing cases,
no suppuration took place.

Case 15. — Charles Von Schack, son of the Chamberlain Von Schack, of
Mecklenburg, was born with a contraction of the right sterno-cleido-mastoideus.
Every thing had been done to cure him, but in spite of treatment the muscle
could not be extended. I divided both the contracted portions, a difficult task,
on account of the liveliness of the child. Some days afterwards a fluctuation
from extravasation of blood in the wound was perceived; a strong compression,
however, produced absorption. The boy became quite straight, and left Berlin
in six weeks after the operation.

Case 16. — Miss Roeser, twenty-three years old, suffered under considerable
obliquity of the neck, towards the right side. I divided both portions of the
sterno-cleido-mastoideus, which separated with a cracking noise. The usual
dressing was employed; a little extravasation took place, but was soon ab-
sorbed.

Case 17. — The subject of this case was six years old; I divided the anterior
and posterior portions of the right muscle; and a fortnight after the operation the
head was perfectly straight.

Case 13. — The boy Moll, four years old, affected with contraction of the right
sterno-cleido-mastoideus, was discharged a fortnight after the operation, perfectly
cured.

Case 19. — Jeshlin, fourteen years old, was afflicted with torticollis in a great
degree, so that the head almost touched the shoulder. The treatment, after the
operation and simple dressing, was that usually adopted. On account of the

Surgery,

229

great degree of obliquity, it became necessary to turn the head to the opposite
side soon after the operation. This gave rise to inflammation, and a large ab-
scess formed. This was accompanied by fever, with nervous symptoms. The
abscess was lanced, poultices were applied, and a simple treatment adopted, by
which the fever subsided, and in six weeks the patient was perfectly well and
straight.

Case 20. — In a boy, aged eighteen months, from the country, affected with
strong contraction of the right sterno-cleido-mastoideus, I divided the anterior
portion of the muscle. A strip of adhesive plaster and a neckerchief were suffi-
cient to effect a cure. This shows that in very young children even the paste-
board is superfluous.

Case 21. — C. Kiesling, six years old, affected with strong contraction of the
left sterno-cleido-mastoideus, was discharged perfectly well four weeks after the
operation.

Case 22. — A boy, five years old, was born with considerable shortening of
the right sterno-cleido-mastoideus; the division of both portions perfectly re-
moved the complaint. A fortnight after the operation no farther after-treatment
was necessary.

Case 23. — The daughter of a merchant, nine years old, had been treated by
machinery for a long time, for extreme contraction of the right sterno-cleido-
mastoideus and distortion of the upper part of the spine. I divided both portions
of the muscle, and, after having closed the wound, employed Glissou’s swing.
After four weeks the head was perfectly straight.

Case 24. — The son of the apothecary Ehrhard, fourteen years old, suffered
under the highest degree of contraction of the right sterno-cleido-mastoideus and
distortion of the upper part of the vertebral column. I divided both portions of
the muscle, but the obliquity was not entirely removed; and, even after the
most careful treatment during seven months, 1 did not succeed in making the
head quite straight. I shall operate again, as the muscle has become tense,
especially at the posterior part.

Case 25. — The son of Buckling, carpenter, six years old, affected with con-
traction of the right sterno-cleido-mastoideus, was perfectly cured in a fortnight,
by dividing both portions of the muscle.

Case 26. — Mr. Dohm, student of divinity, was so disfigured by contraction
of the right sterno-cleido-mastoideus, that it would no doubt have prevented him
from pursuing his professional duties. I divided both portions of the muscle;
and the operation, after a few w^eeks, w^as perfectly successful.

Case 27.-^The son of Mr. Werkenthin, three years old, was affected with a
contraction of the right sterno-cleido-mastoideus. In presence of the Councillor
of State, Arndt, I divided both portions of the muscle, only a few" days ago, and
he will be cured in a short time.

Case 28. — A young man, thirteen years old, apprenticed to a tailor, was
perfectly cured, in a fortnight, by division of the anterior portion of the right
muscle.

Case 29. — Maria Wolgast, eleven years old, daughter of a smith, and a very
intelligent child, was born with contraction of the left sterno-cleido-mastoideus.
Machines had been used during several years, without any success. I divided
both portions of the muscle, and the recovery was so quick, that on the ninth
day the child might have been considered as perfectly straight.

Case 30.--Maria Helucke, eight years old, was born w"ith contraction of the
left sterno-cleido-mastoid muscle. Her five sisters and brothers had all suffered
under the same complaint; four of them died, and one brother w"as greatly dis-
figured by an extreme degree of the disease. The surgeon of the staff, Mr. Mul-
ler, divided the sternal portion of the muscle in the girl, and immediately after
the operation the head became straight. The dressing and after treatment which
was employed, did not differ from that already described. The cure was com-
plete on the third week.

Case 31. — I performed the operation on her brother Charles, twelve years of
age, immediately afterwards, by dividing portions of the contracted muscle. This
No. XLVIL— May, 1839. 20

230

Progress of the Medical Sciences.

case was one of extreme difficulty. The head almost touched the shoulder, and
the contraction of the muscle was uncommonly strong. At the same time the
cervical vertebrae were distorted laterally. After the operation a considerable
effusion of blood ensued, and the fluid became decomposed. The abscess was
opened by a small incision, after which the cure was soon completed.

Case 32. — A boy, twelve years old, was afflicted with strong contraction of the
right sterno-cleido-mastoideus, by which the head was drawn close to the shoul-
der. The vertebrae, of the neck likewise deviated from their normal direction.
Von Graefe had divided the muscle, but by laying it bare before the operation,
according to the old and absolete method. After the wound healed, a new con-
traction of the muscle ensued, and required another operation. This was done
by the same surgeon likewise after the old method. He applied extension, but
without success. According to the account which was given by the father, the
duration of this long though unsuccessful treatment was three months. On
being called in, I found the sterno-cleido-mastoideus strongly contracted, and
very hard at the lower part, a circumstance produced by the cicatrices; on bend-
ing the head to the opposite side, the lower part of the muscle, where it had
been divided, did not project, as it was bound down by indurated cellular tissue.
It became most prominent in its middle part. Here I divided the muscle com-
pletely across, by inserting the knife at its posterior margin, then carrying it
under the muscle, and drawing it back again without injuring the skin; no ex-
tension was employed. The patient was able to leave the room five days after
the operation. No extravasation of blood or suppuration took place; the vertebrae
of the neck remained a little oblique; this, however, gradually ceased.

Case 33. — Charles Lehmann, nine years old, born with a contraction of the
left sterno-cleido-mastoideus, and considerable distortion of the vertebrae of the
neck. I divided both portions of the muscle. No accident followed, and the
cure was complete in eight weeks.

Case 34. — Maria Weber, aged eighteen months, was afflicted with contrac-
tion of the right sterno-cleido-mastoideus and curvature of the vertebrae of the
neck. I divided both portions of the muscle, and the cure was complete in four
weeks.

Case 35. — Miss Epner, of Potsdam, thirteen years old, was born with con-
traction of the right sterno-cleido-mastoideus. She had been treated by ma-
chinery, but without success. I divided both portions of the muscle, and a
perfect cure was obtained in a fortnight.

Case 36. — Albert Wreske, of Brandenbourg, was born with contraction of
the left muscle. The consequence was a well-marked curvature of the vertebrae
of the neck. The weakness of the young man had always presented an obstacle
to all former treatment; a perfect cure was obtained in four weeks.

Case 37. — Maria Zimmer, nine years old, affected with congenital contrac-
tion of the left sterno-cleido-mastoideus. I divided both portions of the muscle,
and a perfect cure was the result.

Remarks. — Of thirty-seven cases operated upon none died, but all, with the
exception of one, were perfectly cured. This One requires a second Operation,
which will be trifling. On one occasion only, severe haemorrhage took place,
but without any bad consequence; and in another the formation of pus rendered
some precautions necessary.

In ail the individuals submitted to my care I have observed some obliquity of
the face; the side at which the musculus sterno-cleido-mastoideus was contracted,
was always drawn downwards, and the other appeared somewhat higher; the
eyelids, angle of the mouth, and the wings of the nose were drawn downwards.
In young children, and where the disease is milder, the face often becomes
straight in a few weeks after the operation. In adult persons, and in the more
important forms of the disease, the bones of the head and of the face are impli-
cated, and months, or perhaps years, are required to restore the natural appear-
ance of the face. In those cases where the vertebral column is deviated, the
restoration of the head to its upright position forces the spine to become straight,
in order to preserve the equilibrium of the body.

Surgery. 231

Of the whole number of cases, contraction of the left muscle existed only five
times. In all the others it existed on the right side. The reason of this could
not be sought in the generally stronger development of the right side of the body,
and in the greater use of the right arm, as the children were either born with
contraction of the muscle, or the obliquity was observed in the tenderest age.

These cases show that the division of the muscle with the preservation of the
skin covering; it, deserves to be preferred to the old method, in which an exten-
sive incision of the skin is made; even in one case it was successful after Baron
Van Graefe had operated twice according to the latter method.

I am much indebted to Drs. Bohm, Berendt, Reich, HolthofF, and Mr. Hilde-
brand t, for their indefatigable care and skill in the a^fter- treatment of these cases,
by which alone these favourable results could be obtained, and in comparison
to which the act of the operation itself is very unimportant. — Lancet, Sep. 22
and 29, 1838. ,

29. Hydrocele. — M. Dujat in a memoir in the Gazette Medicale de Paris, for
September last, gives the following interesting table of the cases of hydrocele,
treated with iodine injections, at the Native Hospital of Calcutta, from the 1st
of January, 1836, to the 5th of January, 1838. The table is compiled from the
registers of the hospital, which were kindly furnished to him for the purpose,
by Mr. J. R. Martin, the original proposer and advocate of this mode of treat-
ment.

AGE.

Right Side.

Quantity of liquid in tunica
vaginalis.

CO to

o y

c s

3 3

O O

1— CM CO o 00

E a

J ^

^ fa

O U.

From 18 to 21

10 4

“ “ 14

6 5

From 21 to 25

29 11

“

“ “ 51

32 13

“

173

From 26 to 35

50 44 38

u » 147

55 45

“

147

179

473

From 36 to 45

18 24

“ “ 72

23 23

257

From 46 to 59

5 6

“ “ 17

“ 1

“

From 60 to 70

“ 2

“

“ “ 4

» 2

112 91

“ » 305

116 89

3 325

370

1000

Left Side.

Quantity of liquid in tunica
vaginalis.

OS '

i § s

c 3 3 3 3

5 O O O O

o Oi cn 05 3S

o o o o

o H

The injection recommended by Mr. Martin is composed of one part of the tinc-
ture of iodine (of Majendie) and three of water, and the quantity of this to be made
use of varies with the size of the tumour. For hydroceles containing from 6 to
30 ounces of liquid, two drachms are sufficient; for those containing from 30 to
60 ounces of liquid, three drachms; and from four to five drachms are required
for those of a larger size. When the hydrocele contains less than 3 ounces, one
drachm of the injection is sufficient. It is the very small quantity of fluid in-
jected, and the retention of it in the cavity of the tunica vaginalis, which charac-
terises the method of Mr. Martin. See the Numbers of this Journal for Nov.
1837, p. 258, and Feb. 1838, p. 484.

232

Progress of the Medical Sciences,

30. Dislocation of the Radius forwards. — An example of this rare accident is

recorded by Mr. Colev', in the Lancet, (10th Nov., 1838). It occurred in a
boy 10 years of age, and was caused by a fall from a horse. The elbow came,
with great force, in contact with a stone on the road, which fractured the inter-
nal condyle of the humerus, and forced the upper head of the radius forwards
over the outer condyle. The forearm was semi-flexed and the hand prone. The
radius admitted of rotation, and its dislocated head could be seen in motion at
the same time in its new situation; the forearm could neither be bent nor ren-
dered straight beyond a certain point. There was a puckering of the integu-
ments just above the dislocated head of the radius, and the fractured condyle
was felt projecting below; so that, at first sight, the displacement appeared to
be lateral. '

The accident having occurred two days before I saw the jiatient, the parts ad-
joining the injury were swollen and inflamed. Extension, according to Sir
Astley Cooper’s directions, was tried without success. I then placed the arm
over the back of a chair with the external condyle uppermost, and confining it
in this situation by an assistant, I bent the forearm downw^ards, gently ex-
tending the hand at the same time, and thus readily replaced the head of the
radius.

31. Extirpation of the Tongue. By M. Regnoli, Professor of Clinical Sur-
gery at Pisa. — A 5mung girl, aetat. 14, of a scrofulous constitution and not re-
gular, was admitted into the wards of M. Regnoli, April 29th, 1838, for a dis-
ease of the tongue. Upon examination, a tumour of the size of a hen’s egg
was observed on this organ, extending from its anterior third to its base, and
filling up all the posterior part of the mouth and the throat. Its posterior
limit could not be discovered. The external edge of the tongue W'as healthy
for the breadth of two lines. The finger carried to the posterior part of the
mouth showed the tumour to extend to the base of the tongue. The whole
thickness of the tongue was comprised in the tumour. The surface of the
tumour was granulated in several points and bled during mastication and after
examinations with the finger. The blood spirted at times as from an artery.
The mass was rather hard than otherwise, was wrinkled and not painful to
the touch. Mastication, deglutition, speech and respiration were so difficult,
that the patient was often threatened with suffocation. The intelligence of the
patient being very limited and her speech difficult, it was impossible to learn
much in regard to the history of the tumour, but it was ascertained that she
had begun to speak with difficulty two years previously. Although it had
been satisfactorily ascertained by the touch, that no liquid w’as contained in
the tumour, yet M. Regnoli judged it proper to make an exploring puncture
into it with a cataract needle: from this nothing but blood was discharged.

Operation. — On the 18th of May, the patient being seated and the head sup-
ported upon the breast of an assistant placed behind her, an incision was made
in the direction of the median line extending' from the symphisis of the chin to
the os hyoides. Two other incisions departing from this were then made, one
to the right and the other to the left, commencing at the upper extremity of the
first incision and extending in the direction of the base of the lower jaw to the
anterior edge of the masseter muscle, care being taken not to wound the facial
artery. From these three incisions there resulted a wound of the form of the
letter T and consequently two flaps. These two flaps comprising the skin, cel-
lular tissue, and the platysma hyoid muscle were dissected back and the mus-
cles beneath laid bare. The operator then plunged a straight bistoury from
below upwards, behind the symphisis of the skin, dividing the attachments of
the genio-hyoid and genio-glossus muscles, perforating the mucous membrane
of the mouth and causing the point of it to appear behind the incisor teeth.
A blunt pointed bistoury was then introduced into the same opening from below
upwards, and the attachments of the digastric and mylo-hyoid muscles and of
the buccal mucous membrane divided, first on the right, and afterwards on the
left side as far as the anterior half arches. But three or four vessels required

Surgery. 233

ligature. The tongue was not forcibly retracted, an occurrence which the ope-
rator was prepared to meet. The floor of the mouth being largely opened by
the incisions, the end of the tongue was seized with the forceps of Museux and
drawn downwards through the opening on the anterior part of the neck. The
tongue was then seized with the fingers and drawn out so as to expose the
whole tumour. The base of the tumour was encircled with several ligatures
in order to prevent haemorrhage from the lingual arteries. To do this a long
curved needle was passed in the muscular mass on the left resulting from the
division of the mylo-hyoid, genio-hyoid muscles, &c. In this ligature en masse
the lingual artery was comprised. A second ligatnre was passed at the poste-
rior part of the tumour, including therein the substance of the tongue parallel
to the os-hyoides. The right lingual artery was secured en masse in the same
manner as that on the left side.

After having included in ligatures the whole circumference of the tumour,
all the parts beyond were removed by repeated cuts with the scissors. At each
cut but a few lines of tissue were divided, in order that any arteries which
might spring, could be tied as soon as divided. No vessel, however, required
the ligature, and the diseased mass was entirely removed without any difficulty.
A small cautery was applied to the stump in order to arrest completely a slight
oozing of blood from it, the ligature which had been passed parallel to the os-
hyoides having become loose under the action of the scissors.

The stump was afterwards re-introduced into the cavity of the mouth. Not
a drop of blood was thrown out into the glottis. The external wound was but
partially closed, and the ends of the ligatures were left hanging out, in order
that the discharge from the parts might be facilitated. The diseased mass in-
cluded almost the whole of tho tongue and the tumour. The latter was of a
fungus nature, whitish and apparently scrofulous.

After the operation, small pieces of ice were directed to bp held in the mouth.
Violent reaction followed, for which she was bled. On the fourth day the
dressings were changed: healthy suppuration. On the eighth day, union was
beginning to take place. The 3d of July, the floor of the mouth was com-
pletel)'^ cicatrised: food and drink were swallowed as well as if the tongue ex-
isted. The hyoidean stump had considerably increased in size, and replaced in
part the functions of the tongue. The speech had in a great measure returned,
the patient speaking much better than before the operation, and she had regained
her flesh and colour. — Gazette Medicate de Paris, December, 1838 — from Bullei-
iino della Scienze Mediche di Bologna.

32. Case of Ileus in which Gastrotomy was performed. By M. Monod, Surgeon
to the Hopital Cochin at Paris. — The patient was a woman aetat. 25, whose general
health had been good till one year previous to her entrance into the hospital,
though occasionally she had been afflicted with pain at the epigastrium and
vomiting. She stated that about one year previously she had received a blow
in the ileo-ccecal region. In the beginning of March, 1838, the pain left the
epigastrium, and was felt towards the lower part of the right side ; and was
attended with colic aud diarrhoea, but no vomiting. The third day after this
attack, a large hard tumour appeared in the ileo-coecal region. For two months
the diarrhoea continued almost constant; and at the end of that time was suc-
ceeded by constipation and vomiting of a greenish transparent matter. Loss of
flesh and diminution of strength followed, and on the 8th of May she entered the
hospital.

Upon examination the tumour in the ileo-ccecal region was found to be three
or four inches in length, and two or three in breadth, ovoid, hard, scarcely sen-
sible on pressure, deeply seated and not moveable. Examination by the vagina
and rectum made known nothing anormal in these passages; but a hardness was
thought to be felt through their parietes towards the right side of the pelvis.

The treatment, consisting in the application of leeches, emollients, enemas and
purgatives was not followed by any benefit.

On the 23d her symptoms were all worse — the character of the matter vomited

20*

234

Progress of the Medical Sciences.

was changed, and ultimately consisted entirely of fcecal matter. A pill of croton
oil was at last successful in producing stools, and was followed by prompt im-
provement— the vomiting ceasing, colic disappearing, and the tumour diminish-
ing in size.

1st, 2d. and 3d. of June, constipation attended with severe pains; vomiting
of bilious and stercoraceous matters again had place. Purgative enemas with-
out benefit followed by a pill of croton oil gtt. ij.

4/A, symptoms continue — Ice is applied to the tumour, and is held in the
mouth — croton oil repeated — enemas of ice water.

There being no amelioration of the symptoms qn the 5th, M. Monod decided
upon performing the operation of gastrctomy at the point of obstruction. An
oblique incision from two and a half to three inches in length was made in the
lower part of the right side of the abdomen, and the muscles carefully divided
down to the peritoneum.

This membrame being divided, a loop of intestine presented itself having a
band of longitudinal fibres, which caused it to be easily recognised as belonging
to the large intestine. This was pushed back into the abdomen, and the fore
finger carried deeply into the cavity made known a hard swelling behind and
above the ccecum. Another loop of intestine was drawn out, which proved to
be the small intestine, and was red and swollen, and did not offer any great sen-
sibility. This was cut with scissors in the direction of its longitudinal fibres to
the extent of about an inch and a half. Immediately a large quantity of fcecal
matter was discharged which occasioned considerable relief. The intestine was
fixed to the edges of the cut by means of sutures, and the wound dressed with
cerate and charpie. Death took place on the morning of the 7th. Autopsy.
Peritoneum much inflamed with a quantity of sero-purulent liquid in its cavity.
The incision in the ileum had been made from eight to nine inches above the
ccecum. The seat of the obstruction was found to be at the superior and pos-
terior part of the ccecum, at its junction with the ascending colon. When
laid open the ccecum showed a contraction so considerable as to admit only of
the passage of a female catheter. On a level with this stricture the ccecum was
firmly adherent to the parts beneath, and was connected with a very hard, whitish,
scirrhus mass of the size of a walnut. — Archives Gemrales^ August, 1838.

[The rage for cutting is we know carried by some Parisian gentlemen to a
sad height ; and this will continue to be the case so long as operations of the
most serious nature are performed in their public institutions without previous
consultations. We cannot for a moment suppose that a consultation of the sur-
geons of any hospital in the city of Paris would have sanctioned the above
operation. Even supposing that the diagnosis had been correct, and that the
case had been one of simple uncomplicated ileus, still the operation would have
been entirely unjustifiable.

In connection with the above, we lay before our readers the following state-
ment which has been recently copied into several of our newspapers from their
French contemporaries. As yet we have seen no mention made in their medical
periodicals of any such decision as that spoken of, though as the statement has
been furnished by the well known correspondent of the New York American,
we have no doubt of its entire truth. Taking the foregoing case, extracted from
one of their most respectable periodicals without a remark, as an example, we
think the decision of the council came none too soon. Such an operation should
meet with unqualified disapprobation, and no means should be left untried to
prevent the performance of them.

“ It having been observed that of late years the mortality among the patients
upon whom operations have been performed in the hospitals of Paris has greatly
increased; the members of the council decided that there should be formed a
monthly report of all the operations performed in the hospitals, specifying the
nature of the operation, the name of the surgeon who performed it, the number
of deaths and cures, and other circumstances. The first report, which has recently
been made, shows that some of the operators have lost two, and even three out of
live of their patients. At the same time, it is proved that the mortality is less since
the establishment of this report.” We can readily conceive of a mortality of

235

Surgery.

three out of five of those operated on, in a service in which gastrotomy is per-
formed for the cure of scirrhous stricture of the intestine. G. W. N.]

33. DesauWs apparatus for fractured femur. — Dr. Davidson states that De-
sault’s apparatus is generally employed in fractures of the thigh bone in the
Glasgow Infirmary ; and that as far as his experience goes, it is better calculated
to preserve the bones in proper position, and to maintain the proper length of the
limb, than the double inclined plane ; but in cases where the fracture is com-
plicated with extensive injury of the soft parts, or of the knee-joint, a relaxation
of the muscles is of essential benefit in preventing irritation and subsequent
inflammatory action. — Edinburgh Med. ^ Surg. Journ. Jan. 1838.

34. Hydrocele treated by acupuncture. — Dr. Davidson reports the two following
cases of hydrocele treated by him in the Glasgow Royal Infirmary by acupuncture.

“ James Snedden, collier, aged 44, was admitted on the 14th of February, 1837.
The right tunica vaginalis was considerably distended, tense, diaphanous, elas-
tic, and afforded a feeling of fluctuation. He complained only of uneasiness of
the loins, caused by the weight of the tumour when standing erect. The swel-
ling commenced about eighteen months ago, but disappeared entirely and spon-
taneously, according to patient’s account, about six months after The re-accu-
mulation of fluid commenced about a year ago, and the tumour has since then
gradually increased in size. A common sewing needle, headed with a little
sealing-wax, was introduced into the tunica vaginalis, and on withdrawing it,
a drop of colourless fluid appeared at the orifice of the puncture. A small piece
of plaster was applied over the puncture, and a discutient lotion afterwards to
the scrotum.

“ On the following day, viz: the 15th, the tumour was found diminished to one-
half its former size, and the testicle was found enlarged and indurated. The
integuments were flaccid, and had a doughy mdematous feel, from the infiltration
of the fluid into the cellular texture. He felt no pain in the parts ; and there
was not the slightest trace of inflammatory action in the neighbourhood of the
puncture.

“ On the 16th of February acupuncture was repeated, on account of a re-accu-
mulation of fluid, though the scrotum was still flaccid. On the 21st, the tumour
had greatly diminished in size, and there was now no fluid in the lower part of
the sac, but there was still some translucency at the upper part around the cord.
The puncture was repeated, and the next day the scrotum was perfectly flaccid,
and there was no translucency in any part of it.

“ On the 1st of March, the tumour was again punctured on account of a re-accu-
mulation, with the result of nearly emptying the sac ; but the fluid again col-
lected ; and on the 6th March it was again punctured in the region of the cord,
transparency and swelling being chiefly situate there. On this occasion, and
also in several subsequent punctures, the needle was removed freely about against
the internal surface of the tunica vaginalis.

“ On the 12th, the swelling had diminished less rapidly than before, and there
was still some fluctuation. The puncture was repeated. He was now put on
calomel and opium, which affected his mouth in about eight days ; and the
punctures were repeated every four or five days until he left the Infirmary on the
8th of April ; but very little change was effected in the swelling, which was
now chiefly confined to the neighbourhood of the cord, and was still diaphanous.
The enlargement of the testicle, however, diminished considerably after the
operation of the calomel and opium.

“ James Kelly, aged 21, piecer, admitted 15th March, 1837. The right tunica
vaginalis was greatly distended with fluid, and was extremely tense and elastic.
The swelling was diaphanous, and the testicle was seen, by transmitted light,
to be somewhat larger than natural at the upper and posterior part. The hydro-
cele commenced originally about three years ago, and has been twice tapped
within the last six months. The general health was good. In this case,
acupuncture with a sewing-needle was performed four or five times, at the inter-

236

Progress of the Medical Sciences,

val of two or three days, with the effect of diminishing the size of the swelling,
but there always remained in the sac a considerable portion of the fluid, and
much more than in the case previously related. He left the hospital after hav-
ing been there about a fortnight; but I understand that he returned in about six
weeks, and that he was tapped and treated by the usual method, by injection, for
the radical cure of hydrocele.

“ This mode of attempting to cure hydrocele radically has excited some attention
of late amongst surgeons, from its novelty and simplicity ; and were it in general
ultimately successful, it would be the most simple and at the same time the
most extraordinary operation that is recorded in surgery. Even upon the sup-
position that it is only a palliative or substitute for the common plan of tapping
with a trocar, the discoverer is entitled to much credit; for a puncture with a
sewing-needle is attended with scarcely any pain, and the most timid of men
would submit to it without apprehension. The results arising from the treat-
ment of two cases are not enough for drawing any certain conclusion; but cer-
tainly they tend to establish this point, that no particular change is effected upon
the internal coat of the tunica vaginalis, and that the fluid reaccumulates as after
ordinary tapping with a trocar.

“ In both the cases that have been detailed, the needle was introduced perpen-
dicular to the surface of the tumour, and in almost every instance, the drop of
clear fluid, which is reckoned characteristic of the acupuncture being properly
performed, presented itself. In the first case, after having simply inserted the
needle for a considerable number of times without any apparent effect in pre-
venting a re-accumulation, it was in the future operations moved about, along
the internal surface of the tunica vaginalis, with the intention of exciting some
inflammatory action. This, however, had no better effect than the simple intro-
duction of the needle.

“ It may be stated that the cases above-mentioned were not well adapted for the
plan, for in both the testicles were enlarged. This certainly is an objection to
the success of the acupuncture, as well as to every other plan for a radical cure
of hydrocele ; but a little enlargement of this organ is a very common occur-
rence in this disease, and in the first case detailed the enlargement had almost
completely subsided before he left the house. It appears to me that this opera-
tion is not likely to supersede the radical cure by injection, but that as a pallia-
tive it ought generally to be preferred to the use of the trocpr; at the same time,
I am of opinion that a frequent and long-continued use of the needle may in some
cases effect a radical cure ; and this view is supported by the fact, that after
acupuncture has been repeated several times, the re-accumulation of fluid goes on
less rapidly than after the first or second operation. — Ed, Med, and Surg. Journ,
Jan. 1838.

35. Dislocation of the Humerus, attended with a grating sensation on motion,
leading to the supposition that the case was complicated with fracture. — Wm. Law-
rence the distinguished Surgeon of St. Bartholomew’s Hospital, in a recent
clinical lecture, related the following case of this character.

“ James Yarmsley, 40 years of age, was admitted into the hospital, on the 23d
of March, 1838, for an accident to the shoulder, which had occurred on the 21st.
A cart, in which he was riding was overturned ; he was thrown violently to the
ground, when the cart fell on him, and he remained under it for some time. The
gentleman who first examined the limb, considered that there was a fracture, and
therefore recommended that he should be sent from the country, where the acci-
dent happened, to the hospital. They who first examined the patient on his
arrival entertained the opinion that there was fracture ; and the case was accord-
ingly mentioned to me as a dislocation of the shoulder with fracture. The dis-
location was obvious enough, and it was soon ascertained that the humerus was
not broken. A sensation like crepitus was perceived as distinctly as in a fracture,
when the shoulder-joint was firmly grasped with one hand, and the arm moved
with the other ; also, when the upper end of the bone was raised by the hand
passed under it in the axilla, the elbow being held by the other hand. The sen-

Surgery. 237

sation appeared to me more like the hitch or catch which might be produced by
moving the articular head of the bone over an irregular hard surface, than the
sharp grating of broken bones : the symptom, however, was so strongly marked
as to lead to the opinion that the neck of the scapula was fractured. Never hav-
ing seen a specimen of fractured neck of the scapula in any museum, and reflect-
ing on the mode in which this portion of the bone is protected against external
violence, I conclude that such an injury, if it ever happen at all, is extremely
rare, and that it is the least likely to take place when the effect of the force has
been spent in causing dislocation. As the existence of dislocation was unequi-
vocal, while I doubted altogether respecting that of fracture, I deemed it advis-
able to make a cautious trial of extension, which I did on the 24th. When a
moderate force had been applied, by two or three assistants pulling at the ends
of a folded linen fastened above the elbow not more than five minutes, the bone
went in, the mobility of the joint was restored, and there was no longer any
crepitus or other indication of fracture.

“ The head of the humerus, when dislocated, may lie upon the subscapularis, or
between that muscle and the bone; or it may be placed in contact with the
inferior costa of the scapula, near the glenoid cavity. In the two latter cases,
the movement of the head over the bony surfaces, on which it rests, may impart
a sensation closely resembling the crepitus of fracture. I remember a case of
unreduced dislocation in this hospital, W’here the crepitus was so distinct that
the injury was supposed to be fracture. The patient died : I do not recollect the
details of the history, nor the cause of death. The head of the humerus was in
contact with one of the ribs, the surface of which was bare.” — London Med. Gaz.
Nov. 17, 1838.

[A case of a similar character came under the care of the Editor of this Jour-
nal in the Wills Hospital in November last. The subject of it was a woman,
from New Jersey, 60 years of age, short stature, robust, flabby muscular system.
Eight weeks previously she had fallen down stairs and dislocated her right
shoulder. Attempts at reduction had been made by a surgeon residing in her
neighbourhood, and subsequently by two surgeons of Bordentown, N. J. with-
out success. On examining her for admission into the hospital, we found the
head of the humerus thrown forward and upwards, under the accronion scapulae,
and were immediately struck with a grating sensation when the bone was moved
in certain directions, which at first led us to suspect that the dislocation was com-
plicated with fracture. There was not however the sharp crepitus of fracture,
but rather a sensation as if two bones covered with cartilage were rubbed to-
gether. The most careful examination failed to reveal any evidence of fracture,
and we felt satisfied that the grating resulted from the rubbing the head of the
humerus against the scapula or first rib.

The patient was suffering no pain from the position of the humerus, had
considerable motion of the limb, and was able to use her hand in sewing, knit-
ting, &c. She was desirous, however, of regaining the perfect use of her arm ;
and it was determined, in consultation with my colleagues. Dr. G. Fox, S. Lit-
tell, I. Parrish, and also of Dr. J. Parrish and J. R. Barton, to make such eflTorts
for the reduction of the dislocation, as prudence justified. These attempts failed ;
and we recommended the patient to be satisfied with her present condition, and
not submit to extreme violence which might produce rupture of the artery and
a fatal result. She went home determined to abide by this recommendation.]

36. Malignant Ulcer under the left ear cured by chloride of zinc. By Wm.
Davidson, M. D. — Neil Boyd, aged 40, servant, was admitted into the Glas-
gow Royal Infirmary, September 13, 1836. Under the left ear was situ-
ated an ulcer about half an inch in diameter, and extending from angle of
jaw to lobule of ear, the under surface of which w'as involved in the ulcer-
ative process. The ulcer was slightly excavated, presenting a dry gray-
ish-colored warty bottom, from which there was occasionally a slight bloody
exudation. Its margins were thickened, callous, and everted, the integuments
being painful on pressure, and of a dusky-red colour. The ulcer first appeared

238

Progress of the Medical Sciences,

above six years ago in the form of a small red papula, which was attended with
a lancinating pain. He complained of a dull uneasy sensation in seat of ulcer,
but the pain was never very acute. No enlargement of submaxillary glands.
On the 13th of September, chloride of zinc, uncombined with flour or gypsum,
was applied to the ulcer, and it has produced to-day (14th) a very thick slough,
which is firmly adherent.

“ September IQth, The slough is detached; the surface of ulcer has a more
healthy aspect, and is covered with purulent secretion. The chloride of zinc
was repeated every three or four days, according as the slough was sooner or
later detached, and was used six or seven times altogether. After the ulcer had
assumed a healthy character, simple dressing, and the occasional light applica-
tion of the nitrate of silver were employed, and he was discharged on the 6th
of November, the ulcer being completely cicatrized. The chloride of zinc in
this case was not combined with any other substance, as is recommended by
some writers; but was simply applied to the ulcer, and allowed to deliquesce on
its surface, using the precaution of preventing any of the fluid formed coming
into contact with the neighbouring parts. Poultices were used during the whole
time that this caustic was employed. The chloride of zinc seems also to answer
well in removing warty excrescences, and I used it lately in a private case for
removing a malignant looking excrescence, situate at the junction of the ala of
the nose and the cheek, about the size of a gooseberry, and partially ulcerated.
It had existed for seven years, was gradually increasing in size, and was the
seat of occasional lancinating pain. The chloride of zinc was applied three
times, at the interval of four days, and after the last slough was thrown off, there
remained a pretty deep excavation, but which was speedily filled with healthy
granulations, and soon cicatrized completely, leaving no suspicious trace of the
former disease.

The chloride of zinc, however, seems only to be superior to many other caus-
tics, in cases when the destruction of a considerable thickness of texture is re-
quired, or where the removal of an excrescence by a caustic is preferred by the
patient to the knife; for the nitrate of silver, as shall be noticed under the article
ulcers, seems to be superior in promoting a sound action, when the unhealthy
stratum of the ulcer is superficiaL — Ed. Med. and Surg. Journ. January, 1838.

37. Treatment and Causes of Erysipelas. — In the Report of Surgical cases treated
in the Glasgow Royal Infirmary during the years 1836-7, by Wm. Davidson, M.
D., we find the following interesting observations on Erysipelas, which pre-
vailed epidemically in the wards during the period mentioned.

In the general treatment of Erysipelas, Dr. Davidson states, that “ the anti-
phlogistic plan was only employed in a few cases in the commencement of the
disease; for it was found that symptoms of debility in general appeared pretty
early, more especially if diarrhoea was a concomitant, which was not unfrequent.
The tonic plan was, therefore, found the most successful, and it consisted of
wine, sulphate of quinine, light nourishing diet suited to the state of the diges-
tive organs, laxatives or laxative enemata, and occasionally opiates at bed-time.
The external treatment consisted of leeches, punctures, incisions, mercurial oint-
ment, nitrate of silver applied in the form of a weak solution to the whole erysi-
pelatous surfaces, or applied in the solid state in the form of a circle, with the
intention of insulating the disease.

Leeches and punctures were not found so beneficial as incisions; and the lat-
ter were generally practised, and made in various parts of the region affected, to
the extent of from one inch and a half to two inches and a half in length, through
the skin and cellular texture. In the slighter cases, where the disease appeared
to be superficial, mercurial ointment, and a solution of nitrate of silver, consist-
ing of ten grains to an Ounce of water, were applied; but the latter was found the
most efficacious of the two; and generally, on the day following its application,
the swelling and redness were much diminished.

“ The solid nitrate of silver succeeded in the great majority of cases, in prevent-
ing the spreading of erysipelas; and the following points require to be attended

239

Surgery,

to, in order to insure success. 1st. It must be applied to a sound part of the
integuments, viz. a part where there is, no swelling or redness; but as near as possi-
ble, so as to avoid this. 2d. The inflamed surface must be completely encir-
cled by the caustic line. This may be effected in the following way. Take a
pretty large hair-brush and moisten thoroughly with water the part that has been
selected to the breadth of about an inch; then rub a cylinder of lunar caustic
very freely over this moistened portion of the skin. Distinct vesication over the
whole surface to which the caustic has been applied should be produced; for if
this does not follow, the disease may extend beyond the line. And this is per-
haps the reason why a saturated solution (consisting of equal parts of the salt
and water) is not so certain as the solid caustic; for erysipelas seems to extend
its boundaries by creeping along the cutaneous surface, before it affects the cel-
lular tissue; hence, if its progress over the integuments can be checked its ex-
tension in the textures below will at the same time be prevented. In general,
after the caustic has been thus applied, the inflamed integuments in the imme-
diate vicinity of it becon^ie partially shrunk and puckered; but the state of the
previously affected parts appears to be uninfluenced by it, and they proceed to
resolution or suppuration, according to the nature of the case. Many cases could
be quoted from the journals of the house, besides those already noticed, where
this practice was adopted, in proof of the general efficacy of this mode of insu-
lating erysipelatous inflammation; but their introduction would render this report
too long.*

“ A question of much practical importance relates to the causes of erysipelas,
in as much as the prevention of the disease, and the separation of those affected
with it from other patients, depend partly upon the opinions formed respecting
this subject. I shall not attempt to discuss the contagious or non-contagious
nature of the disease; or whether it can be generated by overcrowding a wmrd,
and by want of cleanliness and ventilation; but simply state that, on two or three
occasions, almost the whole patients of a particular ward have been affected
with the disease in rapid succession; the first case, being generally a solitary
instance, either occurring in the house, or brought to it when laboring under the
disease. It has been further found, that, for several years back, the disease has
only prevailed, to an epidemic extent, in two particular wards, both situate at
the top of the house, and consequently better ventilated than those situate below
them. These two wards were cleaned out, ventilated, fumigated and heated
with very considerable care; and notwithstanding, the disease, in a short time
afterwards, reappeared. Overcrowding was not the cause, when on this occasion
the disease first returned; though at some other periods the wards were very full,
owing to the numerous important cases that presented themselves for admission.
Whether it be possible that the disease may be spread in consequence of the
promiscuous use of sponges, towels, &c. I am not prepared to give any positive
opinion; but certainly, as long as there is any doubt respecting this point, pre-
cautionary measures for preventing this should undoubtedly be adopted.

“ The conclusions, therefore, which may be drawn from these statements, are

“ Isf. That there should be a ward, in every large hospital, exclusively set
apart for erysipelatous cases; and the reasons for adopting this plan are at least
equally strong, as for the separation of fever from other cases.

“ 2d. That every erysipelatous case should on admission be sent to this particu-
lar ward.

“ 3d. That all cases occurring in the hospital, where removal would not be in-
jurious, should be sent to this erysipelatous ward as soon as the disease is dis-
covered.”—

* It should be remembered that the late Dr. Physick employed blisters with the same
view, that the nitrate of silver has been used by Dr. Davidson. The modus operandi
of the two remedies is the same. — Editor.

240

Progress of the Medical Sciences,

OPHTHALMALOGY.

38. Glaucoma. — The appearances in this disease are usually considered as re-
sulting from some change in the vitreous humor (or hyaloid membrane), the re-
tina, or choroid. The investigations of Dr. Wm. Mackenzie of Glasgow, lead
him to believe that these forms of glaucoma are very rare and that by far the
most common seat of the disease is the lens. He is inclined to think that there
is never any very distinct glaucomatous appearance (that is to say, cloudiness of
a greenish hue), except what is caused by the amber or reddish-brown color of
the central and posterior laminae of the lens. In lenticular glaucoma, the lens
has become, in a certain sense, dichromatic, being of a deep amber when allow-
ed to transmit the light, but appearing green by reflected light; the green hue
being probably the result of the absorption of the extreme prismatic rays of the
light entering the eye, while the middle prismatic rays are but little affected.

All who begin to examine diseased eyes, find considerable difficulty in distin-
guishing lenticular glaucoma from lenticular cataract; but a little experience
generally serves to make them acquainted, more accurately than any verbal de-
scription can, with the diagnostic appearances of these two diseases. No mere
cataract is green; the cloudiness in glaucoma is considerably remote from the
pupil; and though sometimes the cloudiness is limited and surrounded by a lucid
ring, while in other cases it extends almost across the breadth of the lens, yet it
is always evident that the superficial laminae of the lens are transparent in sim-
ple lenticular glaucoma. The greenish cloudy surface is always uniform,
smooth, and as if polished, never streaked, spotted, or apparently rough, as is
generally the case in lenticular cataract. The shadow thrown by the iris on the
greenish cloudy surface is much broader than the shadow thrown upon a lenti-
cular cataract.

“The reddish-brown color,” Dr. Mackenzie observes, “upon which lenticular
glaucoma depends, affects only the internal and posterior laminae, and fades away
into an amber hue towards the surfaces, and especially the anterior surface and
circumference of the lens. These, so long as the disease is one of simple lenticu-
lar glaucoma, have lost comparatively little of their natural transparency, but
the reddish-brown part often presents, on making a section of the extracted lens,
a peculiar dryness of substance, as well as a considerable degree of opacity.

“ After lenticular glaucoma has existed for a time, the surfaces of the lens may
become coagulated and opaque, so as to constitute a complication of glaucoma
with cataract. This sometimes occurs very suddenly.

Dr. Mackenzie has tested these views by an examination of the eye catopti-
cally according to the method of M. Sanson as detailed in a former No. of this
Journal. (August 1838 p. 494.) The following are the results of his observa-
tions. The conditions under which they succeed best are, that the pupil be pre-
viously dilated by belladonna; the observer and patient placed in moderate day-
light; the back of the patient turned towards the window; the patient seated so
that the observer looks rather down into the eye than upwards; and a candle used
which burns steadil}'^, and does not blaze much.

“On reading over the following particulars to Dr. Staberoh, he was kind
enough,” says Dr. M., “ to favour me with a few annotations, which I consider too
valuable to be lost, and which I therefore subjoin under their respective heads: —

“1. In incipient lenticular glaucoma, or what we may call the first degree of
that disease, both the deep erect image, and the inverted one, are distinct.

“ [While its outline remains pretty sharp, the deep erect image is rather larger
in size, and brighter than in the healthy eye. It is also somewhat of a yellow-
ish hue. With the increase of glaucoma the inverted image becomes larger, and
more of a yellowish color; its outline becomes sooner diffused than that of the
deep erect image.

“ In estimating the changes which are observed to occur in the appearances of
the images reflected from the eye in its several diseased states, it is necessary to
take into account two sources of these changes, viz. the state of the surfaces

241

Ophthalmology.

which form the images, and that of the media through which we see them.
Each of these causes must have an effect, more or less remarkable, in different
cases of disease. — J. S.]

“ 2. In mean cases, or what we may call the second degree of glaucoma, the
inverted image is pretty distinct, when formed near the circumferential part of
the crystalline; that is to say, if the candle be moved by the observer towards
the right side of the patient, while the right eye is the subject of examination,
the inverted image will be seen behind the nasal end of the pupil. If the ob-
server now brings the candle slowly in front of the eye, the inverted image, as
it moves across the pupil, is seen to become less and less distinct, and in some
cases is altogether extinguished; but as the candle approaches the patient’s left
side, it reappears behind the temporal edge of the pupil, being again formed by
the circumferential portion of the posterior capsule. No such appearance as
this is seen in lenticular cataract, a disease which always affects the superficial
laminae of the lens in such a way as to prevent the formation of the inverted
image by any part of the posterior surface of the crystalline body. The extinc-
tion of the inverted image, when the candle is placed directly before the pupil,
is evidently owing to loss of transparency in that portion of the lens, which, in
lenticular glaucoma, suffers a peculiar degeneration, characterized by dryness of
substance and a reddish-brown color.

“ [In moderately developed glaucoma, both images of the candle are represent-
ed by yellowish spots, or blazes, of a pretty bright appearance, following the
motions of the candle in their corresponding directions. — J. S.]

“ 3. In complete lenticular glaucoma, or glaucoma of the third degree, the in-
verted image is no longer visible even at the edge of the lens.

“ 4. The deep erect image is better seen in the second and third degrees of glau-
coma than in the healthy eye. It is large and evident, but its outline is not
sharp; so that it often appears like a diffused blaze. It is best seen when the
eye is looked at downwards, and from one side. The fact that it is more dis-
tinct than in the healthy eye, is to be attributed to the reddish-brown part of the
lens serving as a foil to the image.

“ [In the far-advanced stage of glaucoma, both images disappear entirely: but
I am not sure whether, in this case, there is no complication with cataract com-
mencing.— J. S.]

“ 5. In lenticular cataract, no inverted image is visible; while, from the ante-
rior capsule, there is merely a general reflection, but no distinct image.

“ [In incipient lenticular cataract, the inverted image becomes indistinct, and
its outline as if washed off. It is changed neither in color nor in size. It is
extinguished long before the cataract is fully developed. In capsulo-lenticular
cataract, the inverted image fades ranch sooner than in mere lenticular cataract, and
even when the capsule, or the peripheric substance of, the lens, seems to be
alone opaque, the image disappears much sooner than we should expect, from
the apparently moderate degree of opacity. — [J. S.]

“ 6 If the crystalline lens have been removed by operation, neither the inverted
nor the deep erect image is visible.

“ The catoptrical examination of the eye confirms, in the most satisfsetory man-
ner, the doctrine that glaucoma is, in general, an affection of the crystalline lens.
Concerning this disease, Rufus and Galen were right seventeen hundred years
ago; distinguishing by the name of those internal opacities which

they found to be incurable, w'hile on the more favorable, they bestowed the name
of vmxyfA,cna. The former they believed to depend on a change of color and con-
sistence in the crystalline lens, an opinion from which the moderns have erro-
neously departed; while they attributed the latter to the accumulation of a new
substance suffused between the iris and the crystalline — a notion which the mo-
derns have successfully corrected.

“ Lenticular glaucoma may be considered as a nebula of the lens, while cata-
ract may be compared to an albugo, or leucoma. Glaucoma, however, is in the
centre, cataract is on the surface of the crystalline; and while the former is rare-
JNo. XLVll.— -May, 1839, 2i

242 Progress of the Medical Sciences,

ly, the latter is generally unattended with amaurosis.” — London Med. Gaz. April
1838.

39. Use of the essential Oil of Turpentine in Diseases of the Eye. — Dr. A.
Trinchinetti’s experience induces him to place great confidence in the oil of tur-
pentine in the slow and deep-seated inflammations of the eye, especially in those
that do not yield to antiphlogistic measures. Cases are given proving its utility
in chronic inflammation of the iris or ciliary bodies, and in incipient gangrene
of the cornea, all of these following the operation for cataract; in the chronic
stage of rheumatic iritis, or even in the outset, if it be mild ; in traumatic iritis,
ulcers of the cornea, onyx and incipient glaucoma. The oil should be adminis-
tered in emulsion, the dose varying from half a drachm to four drachms daily.*
The phenomena generally following its use are diminution or cessation of pain,
a sense of general comfort, contraction of the vessels with gradual disappearance
of the inflammatory fulness and lachrymation; the early dispersion of the matter
effused into the anterior chamber or between the lamellae of the cornea. Occa-
sionally a sensation of weight and burning in the stomach, especially after full
doses, was felt, and in some rare cases was sufficiently troublesome to prevent
the further administration of the drug. Instead of producing a purgative effect,
it caused constipation ; the urine became abundant, of violet odour, was passed
without pain and deposited a reddish sediment. — Brit, and For. Med. Rev. Oct.
1838, from Giornale delle Scienze Med.-Chirurg. Aug. 1836.

40. Hereditary Hemeralopia. — A very remarkable example of hemeralopia,
hereditary for tv/o centuries, is quoted by M. Florent Cunier, in a memoir read
before the Medical Society of Gand. The first of this race of hemeralopics was a
butcher named Jean Nougaret, of the commune of Vendemian, born about 1637.
The six following generations have all been affected, though in different propor-
tions. The disease affects the descendants of Nougaret from birth, and whe-
ther they remain at Vendemian or reside elsewhere.

The following table gives a synoptical view of this remarkable instance of he-
reditary disease.

1st generation of

children

4th

208

5th

i,i

218

6th

commencing,

123

Thus, of 649 children, 85

have been hemeralopic.

affected with

the disease to

the whole number of births

hemeralopia.

Med. Beige. Dec. 183'^

MIDWIFERY.

41. On the Position of the Placenta in the womb during pregnancy, and on the
manner the latter organ expands therein, as also of its subsequent contractions in
the process of Parturition. — There are some interesting and curious observations
on this subject in the Dublin Journal of Medical Sciences for January last, by
Hugh Carmichael, Esq., one of the Surgeons of Coombe Lying-in Hospital,
Dublin. This accoucheur is of opinion that the placenta does not usually oc-
cupy the fundus of the womb during gestation, but that its true position is at
the posterior part of this organ, probably the lower down the further the gesta-
tion is advanced. He of course admits that the placenta is originally attached
to the fundus of the uterus or near to this part, but he conceives that its change

* The best formula for its exhibition is that proposed by Mr. Carmichael in 1829.

243

Medical Jurisprudence and Toxicology,

of position results from the manner in which the womb, as he imagines, ex-
pands. Thus, he says, that the fundus together with the parts posterior to it,
undergo little or no alteration or change of surface during gestation, beyond
what is sufficient to accommodate the increase of the placenta, and that the ex-
pansion principally goes on at the anterior part. The womb, however, he adds,
increases chiefly in its altitude, the supply of which must, therefore, come
principally from the anterior wall; now the effect of this must be, that while
the posterior part, and so much of the fundus as is occupied by the placenta,
remains stationary, except to the extent first mentioned, that the posterior por-
tion expands and rises up, each superior part of it arriving at and occupying the
fundus, and then turning over to form a portion of the posterior parietes, until
the expansion has gone to the extent required. According to this theory, the
placenta is turned over to the back of the womb by the first act of expansion,
where it continues uninterrupted throughout the remainder of pregnancy, amid
all the activity of the organ upon which it is implanted.

Mr. C. views the grades of uterine contraction as the converse of those of
expansion. Thus when labour sets in, the contractions are conducted on the
anterior part of the womb, the thin fundus likewise participating in them; by
the parts endeavouring to regain their natural position, this latter descends; the
cavity of the uterus is thus lessened, while that part upon which the placenta is
attached, is preserved not only in a perfect state of quiet, but in a condition
whereby the circulation so important to the success of the process is rather
facilitated than impeded; at length, by this means, the child is expelled, and by
that time the placenta arrives at the fundus; it is now no longer required, it is
useless, is then submitted to the effect of these contractions, is detached, and
thrown off from the system.

The occurrence of hemorrhage in labour, Mr. C. thinks may result from par-
tial malposition of the placenta, for if this organ be situated above its normal
position, it will come within the range of the early contractions of the womb,
and be thus partially detached.

42. Unconscious Belivery. — The following very curious case is related by
Robert Hall, Esq. A young villager, about five months pregnant, staid out
of doors during the whole night at a fair. She was speedily attacked with per-
fect paraplegia, and was utterly unconscious of the hand examining the womb
per vaginam — yet she went her full period, and Mr. H. was informed by the
parochial surgeon, Mr. Bond, that she gave birth, unassisted and easily, to a
developed and living child, herself unconscious of its transit into the world.
She died of her disorder some short time after. — London Msd. Gaz. 10th Nov.
1838.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

34. Poisoning with Arsenous Acid successfully treated hy the Hydrated Peroxide
of Iron. — ’A sufficient number of cases of poisoning by arsenious acid in the
human subject, relieved by the administration of the dydrated peroxide of iron,
have now been recorded to inspire confidence in the antidotal powers of this ar-
ticle against the poison just named. A case recently communicated to the
Medical Society of Paris by Dr. Deville, is worthy of a brief notice, as the
antidote proved effectual, though not given until five hours and a half after the
poison had been taken. A young lady, disappointed in love, resolved on sui-
cide. She took a packet of arsenic containing two drachms, put it into a silver
tankard, poured over it about two ounces of w*ater and drank the fluid contents
of the goblet. This was about midnight. She then lay on her bed in expecta-
tion of the result; but finding death not approaching, after some minutes, she
took some of the poison which remained in the bottom of the vessel and endea-

244

Progress of the Medical Sciences,

voured to push it down her throat, but its bitter taste she said made her to spit
out a part of it. Altogether, it seemed on subsequent examination, that she
must have taken and retailed in her stomach about fifty-six grains of arsenious
acid. At one in the morning, the first symptoms of poisoning manifested them-
selves by several attempts at vomiting, and by a feeling of burning heat in the
throat, and in the region of the stomach. It should be mentioned that the pa-
tient had that day eaten a hearty dinner. Fortunately for her, the digestive pro-
cess was not entirely finished when vomiting came on, as a portion of the food
was ejected and with it probably a part of the poison. Soon after the pain be-
came violent, followed by cramp in the calves of the legs.

Dr. Deville saw the patient at four o’clock in the morning. She had at this
time vomited three or four times; she had intense pain in the frontal region, the
face was extremely red; the eyes were greatly swollen and filled with tears;
there was a sense of extreme burning and suffocation in the throat. The pulse
was strong, full and bounding, and acute suffering in the stomach. Dr. D.
supposed he had arrived too late to afford effectual assistance, and gave only
some milk and other drinks, with a view to produce vomiting; and applied a
poultice over the stomach. These means were productive of no relief; on the
contrary, the symptoms increased in intensity.

Dr. Delens was at this time called in, and suggested a trial of the hydrated
tritoxide of iron, which was procured at half past five in the morning, five and
a half hours after the injestion of the poison. The antidote was given in doses
of about one ounce every quarter of an hour until eight o’clock, by v/hich time
nearly half a pound had been taken; ft was then discontinued, as it had pro-
duced vomiting several times and purged twice, and as the symptoms appeared
abating. She still, however, suffered from violent cramps, particularly in the
left leg.

The pulse was still full and bounding; the pains in the epigastrium at times
insupportable, and then almost disappearing. Twenty-five leeches were applied
over stomach, followed by cataplasms and emollient injections.

During this and several succeeding days, the fever continued, accompanied
with the most violent headach, which prevented the patient from enjoying a
moment’s repose. The pain in the epigastrium, however, gradually diminished;
by the aid of warm baths and a soothing treatment, the patient improved, and
after eleven days she entirely recovered.

44. Effects of Respiring Carbonic Jlcid. — By C. T. Coathupe. On the night
of the 24th October, 1838, at twelve o’clock I retired to my library, a room 16 feet
Cinches long, 13 feet 10 inches wide, and 9 feet 4 inches high; its capacity was
2129.82 cubic feet. The chimney was closely built up with bricks and mortar.
The window was very large, but was perfectly tight as to the admission of air.
In this window were two casements, each 3 feet 1 inch high, and 1 foot .2 in-
ches wide; each of them fitted well. The door was 6 feet 5 inches high, and
2 feet 10 inches wide; it fitted well against the stopping strips, but it left a
vacancy of about a twelfth of an inch from the floor; and having a key-hole of
the ordinary size, it may be said to have afforded a space for the ingress or
egress of air, equal to an aperture 3 inches long and 1 inch wide. The tempe-
rature of the room was 54 deg. Fah.

The stove employed on this occasion was on Harper| and Joyce’s principle,
and was about 7 inches in diameter and 16 inches deep. The inverted cone,
through which the air entered at the bottom of the stove, was perforated with
12 holes each about ^ inch in diameter. The ventilator on the top was about
4 inches in diameter, and of the “ wheel” construction; it was left perfectly
open.

The charcoal was of the common kind, and not recently prepared; the stove
could contain 4lbs. avoirdupois of this charcoal, which always required about
two hours combustion before the aqueous vapour was entirely dissipated. On
several occasions I had weighed the stove, with its contents, immediately after
the complete dissipation of its aqueous vapour, and again after an interval of

Medical Jurisprudence* 245

from 3 to 4 hours. The loss usually averaged after the rate of 1 ounce per 18
minutes. When fully charged with common charcoal, 4 lbs. of fuel would al-
ways maintain combustion during from 20 to 21 hours, the ventilation being
quite open all the time. This stove was charged with fuel, and lighted at 11 p.
M. on the night of the 24th inst.; it was placed out of doors for one hour, and
then taken into my room, and placed at a distance of 7 feet from the front of the
sofa upon which I lay, and at right angles to my head. The sofa was 3 feet
wide, and 2 feet high, consequently my head may be supposed to have been
about 8 feet 6 inches distant from the stove, and perhaps about 2 feet 3 inches
above the floor. Having fastened the door inside, I lay down in a thick, wool-
len dressing-gown at 12. At 4 a. m. I felt a slight degree of giddiness, which
was scarcely perceptible, unless any attempt was made to turn upon the pillow.
'I’his increased until a.m., when my sensations resembled, in every respect,
those felt by many persons when at sea, viz., intense vertigo, aggravated by
the slightest motion; a desire to be sick, without the power; great prostration of
strength, and apparent inanition, or want of capability to move any muscle of
the body. To these were added a very full, throbbing, quick pulse, producing
an impression upon the brain as though the arteries were rapidly distended to
their very utmost capacity; the maximum impulse being accompanied by a pe-
culiar thrill, resembling that produced by a light touch upon a piece of catgut,
which had been strained until it was about to break. The cephalalgia was of
unwonted and agonising violence, and particularly affected the occipital regions.
1 felt no symptoms of suffocation, although I could easily have fancied myself
poisoned. It was evidently time to move, so I quickly slid over the edge of the
sofa, and tried hastily to open the nearest window. My strength failed; I fell
immediately upon the cushion of the sofa, and in less than a minute was literally
streaming with perspiration. In a few minutes I made another effort to open
the other window, and with great difflculy succeeded. 1 crawled upon my
hands and knees, to the sofa again, and for a short time remained insensible.
The fresh air, however, soon revived me, and I recovered sufficiently to get to
the door, and opened it, and dragged the stove into the adjoining passage, and
got again to the sofa, where I remained for 13 hours, enduring the utmost dis-
tress. About 7 A.M. my wife came into the room; she saw me very ill, but I
could not give her any information as to the cause. She invited me to take some
pulv. rhei., which was the only medicine she could command. I nodded assent,
and it was with the greatest difficulty that I could sustain myself in any position
to swallow it.

In the course of the day (about 2 p.m.) a medical friend, Mr. T. Davis,
of Nailsea, accidentally called upon me. He saw my predicament, and pre-
pared a few effervescing draughts, which soon set the rhubarb in action. At 7
P.M. I dressed myself, and while everything was fresh in rny memory I tried to
write; but the headach returning with the effort, I was obliged to discontinue.
At 12 last night I retired to the same sofa, all things remaining as during the
preceding night, with the exception of the stove, slept well, and this morning
am almost recovered.

if one ounce of charcoal was consumed in 18 minutes, 18.33 ounces would
be consumed in five hours and a half. If 12.94 grains of carbon be equivalent
to 100 cubic inches of carbonic acid gas (Dr. Thomson), 18.33 ounces, or
8019.375 grs. of carbon will be equivalent to 61973 cubic inches, or 35.85 cubic
feet, of carbonic acid gas. If the respiration of an adult human being consume
the oxygen of 151.1 cubic feet of atmospheric air (vide Essay, p. 13) in 24
hours, it will produce 30.22 cubic feet of carbonic acid in that time, or 6.92 cubic
feet in five hours and a half. Hence the total quantity of carbonic acid gas,
eliminated by both stove and respiration, amounted to ‘35.85-f-6.92=42.77
cubic feet.

Now, the total capacity of the room was 2129.82 cubic feet, and, if we could
suppose the chamber to have been perfectly air-tight, the total quantity of car-
bonic acid that could possibly have existed in its atmosphere at the expiration of
five hours and a half, would have been but 2 per cent.

2l»

246 Progress of the Medical Sciences,

Ctib. ft.

1703.86
383.19
be

42.77

2129.82

I regretted exceedingly, that I could not avail myself of a mercurial trough
which was standing upon a table between myself and the stove, all in readiness,
with receivers filled with mercury, &c., to have retained some of the air of the
apartment before the w'indow was opened; but it was absolutely impossible
for me to have done so at the proper time.

And now comes the point; — Is carbonic acid a poisonous gas (Dr. Christison)!
— or does it kill by suffocation (Dr. Thomson)! I conceive Dr. Thomson’s (!)
opinion to be correct. In my own case, all the symptoms of poisoning were
apparent; and none of those of suffocation, and I attribute them entirely to the
noxious effluvia which escaped with the carbonic acid gas; for unless the carbo-
nic acid did really gravitate, which is not at all probable, the quantity propor-
tioned to the atmosphere was not sufficient, even at its maximum, to have pro-
duced suffocation; and I am certain that I have breathed a larger proportion of
pure carbonic acid gas, without being poisoned.

In the instance of death related by Dr. Christison, of a boy who had been
teazed by a party of smiths, who held a recently-extinguished candle under his
nose, the effect never could have resulted from the carbonic acid gas, but must
have been occasioned by some such noxious principle as so completely enervated
yours, most trul3^ — Lancet, 10th Nov. 1838.

MEDICAL STATISTICS.

45. Vital Statistics of Glasgow. — In April, 1838, Dr. Robert Cowan, one of the
physicians to the Royal Infirmary of Glasgow, read before the Glasgow Statis-
tical Society a highly interesting paper on the statistics of fever and small-pox,
in the great manufacturing metropolis of Scotland — the amount of sickness and
mortality in which, from influenza, cholera and fever, has for several years past,
exceeded the proportion in any other town of the same population in Britain.

The inhabitants of Glasgow are yearly exposed to deleterious influences
which demand the fullest investigation and the most prompt correction. As
the increase of fever, especially during the last seven years, has taken place
not in years of famine or distress, but during a period of unexampled pros-
perity—a period when the wages of labour have been ample— the price of pro-
visions comparatively low, and every individual able and willing to work,
secure of steady and remunerating employment, it cannot be doubted that the
main evil to be overcome is the too crowded state of the population. When to
this radical evil we add the causes enumerated by Dr. Cowan, and which we
regard as active predisponents, there can be little room for surprise at the dis-
tressing prevalence of fevers in Glasgow. These are the total want of clean-
liness among the lower orders of the community; the absence of ventilation in
the more densely peopled districts; the accumulation, for weeks and months
together, of filth of every description in the public and private dunghills; the
over-crowded state of the lodging-houses resorted to by the lowest classes, &c.
The deleterious eflTects of the causes first enumerated by Dr C. cannot be
doubted, but the last circumstance he rnentions, we regard as the primary evil.

We select from the fourth number (January, 1838,) of the London Statistical
Journal, some of the most interesting facts developed by the researches of Dr.
C 0 wan.

The nitrogen would remain as before - - - - -

The oxygen w'ould have been reduced to . - - -

And the carbonic acid, instead of being about 1 cub. foot, would
increased by- - - -

Medical Statistics,

247

With regard to the climate of Glasgow, its main heat is estimated at
Fahrenheit. The average yearly quantity of rain, from an estimate, including
30 years, is ‘22 328 inches. The least quantity in any one year M'as 14.468, in
1803 — the greatest 28.554, in 1828.

That the numbers admitted into the hospital, and the amount of fever cases,
may be compared with the population at different dates, the following table is
given: —

Year.

1791. 1

1801. 1

1811. 1

1 1819. 1 1821. 1

1831.

Population.

66,578 1

83,769 1

110,460

1 147,197 1 147,043 |

202,426

At the census of 1831, the amount of the rural population was 3908, that of
the tov/n 198,518.

The increase of population in Glasgow is to be chiefly ascribed to immigra-
tion, and the demand for females — domestics and labourers in the numerous
cotton and power-loom factories and bleach-fields in the neighbourhood of the
city, being very great, the largest proportion of the immigrants are of this sex.
Those who resort to towns for employment are generally between the ages of
15 and 25, a fact which has an important bearing ‘upon the statistics of fever.
The relative proportion of the middle and wealthy orders to the labouring class
has been yearly diminishing, and hence one cause of the increasing mortality of
Glasgow.

The following tabular view of the amount of population, and rate of mor-
tality, for the 14 years from 1821' to 1835, inclusive, is taken from a letter ad-
dressed by Henry Paul, Esq., to the Lord Provost.

Years.

Population.

Burials.

Rate of Mortality.

1822

151,440

3690

41*00

18*33

156,170

4647

33*75

1824

161,120

4670

33*94

1825

168,280

4898

33*94

1826

171,660

4538

37-82

1827

177,280

5136

34*51

1828

183,150

5942

30*82

1829

189,270

5462

34*71

1830

195,650

5785

37*73

1831

202,420

6547

30*91

1832

209,230

10,278

20*35

18.33

216,450

6632

32 63

1834

223,940

6728

33*28

1835

231,800

7849*

29*53

Mean mortality from 1821 to 1835 inclusive, 1 : 33*24

1836 244,000 9143 1 : 26*687|

The Royal Infirmary, for the reception of medical and surgical patients, wa.s
opened in the month of December, 1794, and contained accommodation for
about one hundred and fifty patients. An addition was made to it in 1816, con-
taining 80 beds. One-half of the Fever Hospital was opened in 1829, and the
othet in 1832, and, with some additional accommodation afforded since, can now

receive two hundred and twenty patients.

The permanent hospital accommodation was —

From 1795 till 1816 ------ 150 beds.

1816 till 1829 230

1829 till 1832 330

1832 - 450

At which it still remains.

But besides the permanent hospital accommodation, stated in the foregoing

* In the burials from 1822 till 1835, there were included 6257 still-born,
t Of the 9143 burials in 1836, there were 702 still-born.

248

Progress of the Medical Sciences.

table, it has, on various occasions, been absolutely necessary to provide tem-
porary hospitals, and also to appropriate apartments within the Infirmary for the
reception of patients, apartments never intended for any such purposes. These
demands for additional room have been solely caused by the prevalence of
typhus fever, with the exception of the hospitals required in 1832 for the recep-
tion of patients affected with cholera.

In 1818, a temporary Fever Hospital was erected at Spring Gardens by pub-
lic subscription, fitted to contain 200 patients. It was opened on the 30th
March, 1818, and closed on the 12th July, 1819.

This hospital was again opened in 1827; at the expense of the Infirmary, and
kept open for five months.

In 1828, a temporary booth was erected in the Infirmary grounds, capable of
containing 68 patients.

A Fever Hospital, with 135 beds, was opened at Mile-End on the 9th Jan-
uary, 1832, and closed the same year.

Notwithstanding the above amount of hospital accommodation, that portion
of it allotted for the reception of fever patients has, on various occasions, been
found insufficient, and numerous applicants for admission have been thrown back
upon their own resources — left to spread the contagion of typhus around their
miserable dwellings, thereby augmenting the sum of human misery already ex-
isting in its most appalling forms.

The first table exhibits the total number of patients treated in the Royal In-
firmary from its opening in December, 1794, till the 1st January, 1837, distin-
guishing the number of fever patients each year.

Tables of the total number of patients treated in the Glasgow Royal Infirmary^
fron 1795 till 1836, distinguishing the number of fever patients each year.

Year.

Total.

Fever.

Year.

Total.

Fever.

Year.

Total.

Fever.

1795

226

1802

729

104

1809

886

1796

338

1803

806

1810

935

1797

545

1804

678

1811

826

1798

569

1805

719

1812

877

1799

631

128

1806

700

1813

1022

1800

733

104

1807

726

1814

1135

1801

702

1808

840

1815

1340

230

1st period.

3744

! 484

2d Period.

5198

512

3d Period.

7022

574

Year.

Total.

Fever.

Year,

Total.

Fever.

Year.

Total.

Fever.

1816

1511

399

1823

1759

269

1830

2010

729

1817

1886

714

1824

2091

523

1831

3183

1657

1818

2289

1371

1825

2438

897

1832

2974

1589

1819

1861

630

1826

2317

926

1833

3082

1288

1820

1570

289

1827

2725

1084

1834

3879

2003

1821

1454

234

1828

3133

1511

1835

3260

1359

1822

1596

229

1829

2321

865

1836

5130

3125

' 4th Period.

12167

3866

5th Period.

16784

6075 ^

i 6th period.

23518

11750

For the last three or four years, patients with small-pox and scarlet-fever have
been included in the returns of fever.

Medical Statistics,

249

In the first septennial period,

In the second,

In the third,

In the fourth.

In the fifth.

In the sixth.

If to this table, strictly applicable to the Royal Infirmary, the numbers treated
in the temporary hospitals be added, the per centage in the fourth period will be
raised, from 31.77 to 47.62; whilst that of the sixth period will rise rrom
49.96 to 54.83.

The number of fever patients treated in the Infirmary during the last seven
years, amounts to 11,7.51, whilst the total amount during the first thirty-five
years was only about the same, namely, 11.511.

The distressing rate of mortality existing in Glasgow is rendered the more
conspicuous by comparison with that of other manufacturing towms. Thus,
for example, Manchester, with a population at the last census of 227,808, and
which, in its constitution and density must nearly resemble that of Glasgow,
has been for years, and yet remains comparatively free from fevers. The ave-
rage annual number treated in the Manchester Fever Hospital for seven years,
ending in 1836, w*as - - - - - . 497

That of Glasgow during the same period, - - . 1842

The number treated in Manchester Hospital in 1836, was - 780

“ Glasgow “ “ - 3125

For some causes not well understood, a great change has taken place in the
rates of mortality in the two cities compared.

From 1797 to 1806, both inclusive, the number of the fever patients treated
in the Glasgow Infirmary was only 883, whilst those treated in the Manches-
ter fever Hospital amounted to 4618.

In Leeds, another manufacturing city, with a population at the last census of
123,393, the number of patients affected with fever and treated in the Hospital,
averages for the last seven years, only 274.

In Newcastle and Gateshead, with a population of 57,917, the number of pa-
tients treated in the institution for the cure and prevention of contagious fever,
amounts in the last seven years to only 276, or 39 per annum.

In Liverpool, with a population of 189,242, there were 1700 cases of fevers
treated in the Hospital during 1836, a large proportion of which were seamen
of the port, a numerous class.

Dr. Cowman observes, that further comparisons of the rates of fever in other
towns in England, contrasted with that subsisting in Glasgow, would, he fears,
only place the insalubrity of the latter in a more prominent and alarming point
of view.

In Edinburgh, with a population of 162,156, the number of fever patients
admitted in the Royal Infirmary, for the last three years, has been 2270, giving
the average of about 756 per annum.

Dr. Cowan gives a table exhibiting the number of cases of fever patients
treated by the district surgeons for the years preceding and including 1836.
The w'hole number of cases was 9340, of which 3138 were sent to the Infirm-
ary and 6202 treated at home. This shows the arduous and dangerous duties
imposed on the district surgeons, from fevers alone. Few of these gentlemen,
he says, escape an attack. The salary allowed each is 21/. per annum, a sum
quite inadequate for the duties performed — riiotwithstanding which the situations
are sought for with an eagerness denoting great professional ardour.

The Glasgow Fever Hospital can accommodate, without being over-crowded,
220 patients. From the 31st of October, 1835, till the 1st of November, 1836,
there were 2655 admissions, of whom 142 were treated by the clinical physi-
cians, and 2513 by Dr. Cowan himself. The numbers admitted each month

the fever patients treated in the Infirmary were
12.92 per cent, of the whole.

9.84 “ “

8 17 “ “

31.77 “ “

36.19 “ “

49.96 “ “

250

Progress of the Medical Sciences,

were as follows: — 1835. Nov. 124 — Dec. 140. 1836. Jan. 141~Feb. 125 —

March 176— April 203— May 246— June 272— July 264— Aug. 306— Sept. 303
—Oct. 355.

The average residence of each patient in the Hospital was 18 days. The
males and females were nearly equal in number.

Although the Fever Hospital is strictly appropriated to the reception of pa-
tients labouring under fever, small-pox, scarlet fever, measles, and erysipelas,
still patients afflicted with other ailments, are occasionally sent there, either
from their diseases being mistaken for fever, or from the facilities of admission
being greater than those of the Infirmary.

Dr. Lombard, of Geneva, estimates the Irish population of Glasgow at
60,000, and ascribes the prevalence and what he deems the peculiarities of the
last named city, to the number of Irish residents. The same opinion is ex-
pressed by the author of the article “ Vital Statistics,” in McCulloch’s Statis-
tics of the British Empire, vol. ii. p. 572. But these statements are proved by
Dr. Cowan to be incorrect. The proportions of the Scotch, English and Irish
inhabitants is ascertained by the census of 1831 to be as follows: —

Scotch. English. Irish. Foreigners. Total.

163,600 2919 35,554 353 202,426

Tlie respective portions of fever patients were 66.10 per cent. Scotch, 2.12
percent. English, and 31,67 Irish.

From an examination of the tables showing the ages of the patients admitted,
distinguishing males from females, it appears that the period of life at which
fever is most liable to occur, is from the age of 20 to 25 years for males, and
from the age of 15 to 20 for females. The admissions rapidly diminish after
the age of 40. Of 2257 individuals aflfected with fever, 2075 were under the
40th year, and only 182 above it.

It appears not a little remarkable, that whilst the ratio of mortality among the
males is as great as 1 in every 6 121-163, that of the females is only 1 in every
11 21-101; the mortality of the males is 14.87 per cent.; that of the females
8.92 per cent. At the age of 15, the rate of mortality is nearly equal for both
sexes. At the age of 30, the proportion of male deaths is nearly double that
of the females. The mortality of males under 20 years of age, is 6.04 per cent,
of the cases; that of the females under 20 4.90 per cent. The total mortality
under 30 years of age is 8.35 per cent.; above 30, 24.84 per cent.

The increasing rate of mortality in Glasgow has been ascribed to the preva-
lence of fever, but Dr. C. shows that small-pox has had its share in augment-
ing the mortality. Unlike fever, however, the last named disease exerts its
influence during infancy, and to it, in a great measure. Dr. C. attributes the in-
creased mortality under ten years of age.

The deaths from fever, in 1835, were 412 by small-pox 473
“ “ in 1836, “ 841 “ 557

Of the deaths from fever, only 186 were under the tenth year, whilst the
deaths of small-pox under the tenth year amounted to 993. G. E.

46. Periodical Mortality of the Human Race. — At the termination of the first
twelve years, about one-third of those born are with the departed; the proportion
being against males in the ratio of 855 to 732 females (yearly). After this term
(twelve years) to the age of forty-four, the middle period of life, and by far the
more hazardous to women, the comparative mortality shows a different result;
being as forfy-six females to forty-one males. At the termination of this period,
when procreation ceases, female life is comparatively the most secure; the
average mortality from the ages of forty-five to sixty-five being about as sixty-
three males to sixty females. The comparative security of life subsequent to
this is slightly in favour of females. The table shows a great excess of mor-
tality among females; but it should be remarked that the excess of female popu-
lation, after" this period of life, is nearly twelve per cent, over the male, and the
ratio of mortality is hence by so much greater, without indicating any compara-

Animal Chemistry, 251

tive insecurity of life. In collating this table from the official documents before
us, we cannot but remark the extraordinary mortality it evinces at the termina-
tion of each decade of man’s life from the age of thirty years. In every instance,
from thirty years of age and upwards, the mortality in the year which terminates
the decade very greatly exceeds that in the preceding and succeeding years; and,
as a matter somewhat curious, we shall show these instances: —

Age.

Mortality;

Age.

Mortality.

Age.

Mortality.

29 -

26,630

49 -

23,680

69 -

33,038

30 -

31,027

*50 -

33,527

*70 -

53,963

31 -

23,201

51 -

20,911

71 -

32,162

39 -

22,778

59 -

25,782

79 -

32,162

*40 -

33,503

*60 -

43,273

*80 -

45,617

41 -

20,989

61 -

26,084

81 -

27,425

This strikes us as something extraordinary; it seems to say, that, at these
periods, a man is under the influence of some physical change, when he either
surrenders or renews his life lease. — Browning's Domestic and Financial Condi-
dion of Great Britain.

47. Greater number of still-born in illegitimate than in legitimate births. — It is
well known that unmarried females who become pregnant are ipuch more likely
to have still-born children than married women. Professor .Torg, in a recent
work {^Die Zurechnungs fdhegkeit der Schwangern und Gebdrenden beleucMet')
states that in Leipzic, in 1835, there were born 1131 legitimate and 249 illegiti-
mate children, of which 45 of the former and 28 of the latter were still-born ;
being one illegitimate child still-born in 8 25-28 births ; and one legitimate child
still-born in 25 6-45 births. In 1826 there were born 1135 legitimate and 242 ille-
gitimate, of which 52 of the former and 18 of the latter were still-born; the ratio
being in legitimate births one still-born in 21 43-52 berths, and in illegitimate
one still-born in 13 8-18 births.

48. Pauper Lunatics and Idiotsin England and Wales. — It is stated in the No. of
Statistical Journal for October, 1837, that there were in England and Wales 13,667
pauper lunatics and idiots. Of this number 2834 were male lunatics and 3568
female lunatics ; 3372 male idiots, and 3393 female idiots. The proportion which
the number of pauper lunatics and idiots bears to the population generally, is greater
in the agricultural than in the manufacturing and trading districts. Taking the
whole population of England, there is one pauper lunatic or idiot for every 1038
persons, and in Wales, one for every 807 persons ; and upon the population of
England and Wales together there is one for every 1017 persons. The greatest
number of lunatics and idiots, in proportion to the population, is to be found in
Rutland, where there is one for every 497 persons, and the smallest number in
Lancashire, where there is only one for every 1960 persons. The number of
criminal lunatics in England, on the 12th July, 1837, was 178, of whom 138
were confined in asylums, and 40 in gaols.

ANIMAL CHEMISTRY.

49. Urea in the Blood in Cholera. — In a recent Number of Poggendorf's Annals^
it is stated that Marchand detected slight indication of the presence of Urea in
the blood of a patient who was affected with cholera, and who had not passed
urine for three days. Still more recently Dr. Harry Rainy, of Glasgow, has
distinctly detected urea in the blood of a patient who had died with all the symp-
toms of Asiatic cholera. The patient, a female, was ill eleven days, during which
only 36 ounces of urine was secreted, including a small quantity found in the blad-
der after death. The blood analyzed was taken from the larger vessels and heart.

252

Progress of the Medical Sciences.

There was detected rather more than one grain of urea in each ounce measure of
blood. — London Medical Gazette^ 1839.

50. Analysis of the Liquor Amnii. — Dr. G. 0. Rees has made a chemical ex-
amination of the liquor amnii in four cases, obtained at the 7 1-2 month of utero-
gestation. The results show that this fluid varies greatly in proporiional con-
stitution in different individuals, at the same period of utero-gestation, so that,
like all the secretions of the body, it is affected by the temperament and diathesis
of the mother. The specific gravity of the secretions, however, varied but little
in the specimens examined by Dr. Rees (1007. to 1008.6), a piecaution, he
thinks, on the part of nature to preserve a medium of fixed power to oppose the
motions of the foetus in utero. »

The experiments of Dr. Vogt, of Berne, (see this Journal for Nov. 1837, p.
219,) would lead us to suppose that there is a great variation in the density of
the fluid at different periods. Dr. Rees does not regard those experiments as
conclusive, as there is a want of proper relation between the solid contents and
specific gravity of the fluids, as given by the Swiss chemist. — Guy's Hospital
Reports^ Oct. 1838.

MISCELLANEOUS.

51. Revaccination. — Upon this important subject, which is at present very
much agitated in France, there is an interesting memoir by M. Dezeimeris, in
1.' Experience Journ. de Med. et Chirurg. for December last.

According to this writer, the idea that the preservative effects of vaccination
have but a limited duration, and that it may be necessary to renew its impres-
sions, at longer or shorter periods, is founded upon two fundamental facts: —

1. Variola, although a preservative from variola, does not afford an infallible
and ever-enduring protection from the same disease. Repetitions of variola are
never observed following each other closely, but with long intervals from the
first attacks. The preservative power is, therefore, at its hightest degree, im-
mediately after the body has been exposed to the principle of the disease, and
gradually becomes weaker in proportion to the length of time elapsing after this
epoch.

2. The practice of inoculation for small pox has shown, that the variolous
virus produces a milder form of disease than that resulting when taken the natu-
ral way; that the virus becomes milder and milder in the course of successive
transplantations; from all which it seems reasonable to conclude that in losing
strength during successive reproductions, it also loses its protective power.

Upon these grounds it is allowable to presume tl^at vaccination, the resem-
blance of which to variola is so striking, must be subjected to similar laws. It
is naturally to be doubted whether the preservative power of vaccination ought
to be regarded as absolutely unalterable, and it may be presumed that the virus
obtained from the cow would become more and more feeble after successive
transplantations through the human system. Prudence would, therefore, seem
to dictate the necessity of returning from time to lime to the original source of
the vaccine virus.

Now these conclusions were entertained by the first originators and promoters
of vaccination, and promulgated by Jenner himself. But it has been chiefly
since the year 1820, from which period so many epidemics have prevailed, cal-
culated to throw doubts upon the question of the infallibility and unalterability
of the preservative powers of vaccination and variola, that the greatest number
of authors have occupied themselves upon the question of revaccinalion.

M. Dezeimeris commences his examination of the evidences upon this sub-
ject, by reference to the documents furnished by the northern countries of Europe.
A few estimates, taken from the Copenhagen bills of mortality, will prove more
than all reasoning upon the subject, the degree of preservative power exerted by

Miscellaneous,

253

vaccination during the first years of its adoption. From the year 1749 to 1808,
there perished by small pox in the Danish Capital the following numbers: —

1749 to 1758

2991

persons.

1759 to 1768

2068

((

1769 to 1778

2224

((

1779 to 1788

2028

((

1789 to 1798

2920

((

1799 to 1808

724

((

It must be observed, that in the first two years of the last period, vaccination
had not yet been established.

The following facts, furnished by subsequent years, are worthy of attention,
as possessing striking interest. From 1800 to 1804, not a single case of small
pox occurred among the vaccinated. In 1804, two cases of varioloid occurred.
In 1805, five persons died in Copenhagen of varioloid. In 1806, three more of
the vaccinated fell victims to varioloid. In 1808, there were 46 deaths by small
pox, including 13 cases of varioloid. In 1819, and more especially in 1823, the
cases of varioloid and genuine variola occurred in greater number, and were not
limited to Copenhagen. It is of importance to mark the ages of the victims of
small pox after vaccination, since it furnishes the means of ascertaining the
period that has elapsed from vaccination. The following information upon this
point is derived from the documents: 24 of the subjects were under the seventh
year; 42 between 7 and 11; 191 between 12 and 23; so that in nine-tenths more
than ten years had elapsed after vaccination. Three of the victims had genuine
confluent small pox; they had been vaccinated on its first introduction. Thus
it appears, that the most violent cases, such as terminated fatally, and, conse-
quently, those in whom there no longer subsisted either the privilege of being
preserved from the disease, nor even the power of mitigating its violence, were
precisely the cases occurring in those that had been the longest vaccinated.

In 1825, a new epidemic commenced in the month of September, which did
not terminate before the middle of the year 1827. The records furnish the fol-
lowing particulars: In 623 cases of variola or of varioloid, 428 occurred among
those who had been vaccinated; 26 among these had variola, in a form which
differed in no respect from that occurring .among the vaccinated, and two of
these died. This mortality, so very small when compared with that occurring
among the unvaccinated, with whom 1 in 5 died, proves that vaccination, even
where it does not preserve entirely from the contagion, lessens its malignity.
The documents also prove that the proportion of the vaccinated attacked by
small-pox, becomes greater and greater from year to year, and that the suscepti-
bility to variola is in direct proportion to the time that has elapsed after vaccina-
tion. A new epidemic occurred in 1828, the characteristics of which differed
in no respect from those of former years. Of the subjects which the public
authorities had revaccinated in 1825, not one was known to be attacked.

In 1832, the epidemic was still more violent, and revaceination preserved the
power it had before shown in protecting from attacks of the contagion.

The following results connected with this period, are furnished by Dr. Wendt;
it includes observations made upon 3984 cases of revaccination:

Age.

Successful Revaceinations.

Unsuccessful.

1 to 10

10 to 20

216

20 to 25

2175

998

25 to 30

191

30 to 40

123

40 to 50

2756

1208

The facts furnished by Denmark, therefore prove; I. That for some years the
variola affords a perfect protection against variola; after which its preservative
No. XLVIl.— May, 1839. 22

254 ‘

Progress of the Medical Sciences,

virtue no longer prevents a second attack, although it exerts a modifying agency
in a greater or less degree. Finally, after the lapse of a certain period, it neither
prevents variola from occurring, nor from pursuing its natural course, nor even
from proving fatal.

2. That vaccination affords an absolute protection from variola during some
years, after which it does not prevent a second attack, but still exerts a modify-
ing agency over the disease, to a greater or less degree. Finally, after a certain
period, it neither prevents the variola from appearing, nor from running its ordi-
nary course, nor from causing death.

3. That in regard to absolute protection, revaccination enjoys the same power
as variola and vaccination; that it succeeds the more certainly in proportion as
the individual upon whom it is practised is removed from the period when he
had the small-pox or the cow-pox, and consequently as the necessity is greatest.
It is proper to observe that it would appear from the observations furnished by
epidemics, that the preservative power exerted by revaccination is temporary,
just as is the case with that afforded by variola and first vaccination. From all
this, one is forced to declare that both experience and reason dictate the neces-
sity of revaccination, and that it should be propagated with as much zeal as first
vaccination.

52. New Works. — The following medical works have recently been published
in France.

Memoire sur la cure radicale des pieds-bots. Par H. Scoutteten. 3 fr.

Traite theorique et pratique des maladies des femmes. Par J. Imbert, tom.
Ire. 6 fr. The second and concluding volume is promised in six months.

Anatomie comparee du systeme nerveux. Par F. Leuret. Ire Livraison. To
he completed in 2 vols. 8vo., and 1 vol. folio, of 33 plates. With uncoloured
plates 48 fr. With coloured plates 96 fr,

Des pertes seminales involuntaires. Par M. le Prof. Lallemand. 2d partie.

Traite theorique et pratique des alterations organique simple et cancereuses
de la matrice. Par F. Duparcque, D. M. 2d edition entirely remodelled and
enlarged, 7 fr.

Traite de pathologie exteme et de Medecine operatoire. par A. Vidal, (de
Cassis.) tomes 1 et 2, 8vo. To be completed in five vols.

Maladies des enfans — affections de poitrine. Ire partie Pneumonie. Par
MM. Rilliet et Barthez, internes des hopitaux.

Recherches cliniques sur la meningite des enfans. Par M. A. Becquerel, in-
ternes des hopitaux.

255

AMERICAN INTELLIGENCE.

On the Catoptric examination of the Eye. By The Editor.—
In our number for August, 1838, we gave an account of a new means of
Diagnosis between Amaurosis and Cataract, discovered by M. Sanson.
This surgeon observed that, when a lighted candle was held before an eye,
the pupil of which was dilated, and in which there was no obscurity of the
transparent tissues, three distinct images of the flame were visible ; two
upright and one inverted. Experiments made to determine the causes of
these reflected images, and the changes which occur in their number, posi-
tion, &c. have shown, that if a light be placed before the convex face of a
single watch glass, or of several arranged one behind the other, one or
more upright images of the flame will be seen according to the number of
glasses used.^ Now in the eye there are two superimposed convex sur-
faces, viz: 1. the cornea, 2. the anterior capsule of the crystalline lens.
Thus the^formation of two upright images is explained.

Again, if a light be placed before the concave surface of a watch glass
an inverted image is seen. Such a surface exists in the eye, in the poste-
rior capsule of the lens ; and thus the third image is accounted for.

We have been led by the statement of M. Sanson to examine the eye
catoptrically in a number of cases within the last ten months, and the results
of our investigations are entirely confirmatory of the representations of that
distinguished surgeon. But it is not merely as a means of diagnosis be-
tween cataract and amaurosis, that this method of examining the eye is
useful. The colour, size, distinctness, &c., of the reflected images enables us
to distinguish many conditions of the transparent tissues of the eyes, which
could not, by any other means, be diagnosticated. Dr, Mackenzie of Glas-
gow has recently employed it to determine the seat of the different varie-
ties of glaucoma, and it is capable of further application. In fact, we are
persuaded that the catoptric examination of the eye will prove as useful
a means of diagnosis in various alterations of that organ, as auscultation
and percussion are for those of the chest.

It should be borne in mind that very careful examination is usually re-
quired before those who are unaccustomed to observe them are able to
detect the reflected images — once noticed, however, they are afterwards
readily seen.

Dr. John Neill, the intelligent resident surgeon at Wills Hospital, has
constructed some models which serve to illustrate these catoptric pheno-
mena, and to assist the student in detecting the reflected images. These
models are formed of three watch glasses. Two of them are of the same
size and smaller than the third. The former are attached together with
their concave surfaces opposed, so as to represent the capsule of the lens,

* At least so it is staled. But in truth each image is double — one being reflected
from each surface of the glsss ; and these images are the more distinct the thicker the
glass is.

256 American Intelligence,

and are inserted in a hole made in a circular piece of pasteboard. This dia-
phragm thus constructed, is placed in a pasteboard cylinder or circular box
near one end, and this end is covered with the larger glass, to represent
the cornea. The other end of the box is closed, and the parts described
are kept together by strips of paper and paste. We have thus a good rep-
resentation of a natural eye. To represent the opacity of the capsule, other
models are made with paper pasted on one or the other of the reflecting
surfaces. With a little ingenuity models may thus be made to exhibit
sufficiently well most of the different conditions of loss of transparency of
the tissues of the eye.

Our investigations are not sufficiently matured to authorise us to lay
them at present before the public, but we hope in due time to communi-
cate the results.

Expulsion of one twin Foetus, the other retained to the full period,
By S. Jackson, M. D., late of Northumberland.

When 1 wrote my note on the expulsion of one twin foetus, with the
safe retention of the other to the full period of utero-gestation, published in
Vol. XXII. p. 237, of this Journal, I was not aware that similar cases had
been recorded. Hence there is an act of justice to be awarded to our
learned friend. Dr. James Mease, who lately referred me to a paper which
lie published on the same subject, in the Eclectic Repertory for the year
1819, vol. IX. p. 531.

Dr. Mease there relates four cases ; a general idea of which may here
be given in a few words.

Case I. In this the abortion occurred about the fourth month of preg-
nancy, under Dr. Mease’s own observation, and a delivery of a child at
the full lime, five months afterward, occurred to Dr. Wm. Gardner then
of Darby, near this city.

Case II. Dr. Mease quotes from the London Medico-Chirurg. Transact,
vol, IX. p. 195, as recorded by Mr. John Chapman of Windsor. A
blighted foetus with a perfectly healthy placenta was expelled with much
pain and considerable flooding ; the other foetus was carried to the full lime
and the woman had a fortunate accouchement.

Case HI. In the Transact, of the Royal Society of London for 1818,
Dr. Granville refers to a case related in one of the volumes of the College
of Physicians, of London, entitled “ a case of superfoetation.” A lady was
delivered of a male child in November, 1807, and in three months after-
ward, she was delivered of another male child, “ completely formed.”
The first died when nine days old, the other lived longer.

Case IV. “ I have now under my eyes,” says Dr. Granville, loco cit.,
“a recent preparation, where the complete ovum is seen, such as it was
when expelled at the seventh month of pregnancy, the lady being safely
delivered of another child alive two months afterward. Although the first
foetus was expelled at the seventh month, it was evidently the growth of
a shorter period, and had remained in the uterus dead for three months.”

Closure and Obliteration of the Os uteri, during pregnancy. By
Samuel Webber, M. D. of Charlestown, N. H. — Early one morning I

was called upon to attend Mrs. O , aged 28, in labour with her first

child. The pains were said to have been regular and of moderate strength
all night. Upon examination I found a large rounded tumour pressing

257

American Inlelligence.

well down into the vagina, but could at first discover no os uteri. After
a prolonged and careful examination, I found a little back of the centre of
the tumour a slight inequality ; consisting of a very shallow depression or
dimple, just admitting the tip of niy finger with a little inequality in the
edges surrounding it, a very slight protuberance being perceptible before
and behind it. The cavity of the dimple was smooth and firm. It im-
mediately occurred to me that from some inflammatory action union had
taken place between the lips of the os tincse, thus obliterating it, while
the cervix had been completely dilated, either by the growth of the child
or by the parturient action. As the pains were not excessive, I determined
to wait, with the hope that their progressive action would either overcome
the adhesion of the opposing surfaces, or so dilate and enfeeble the point
of union, that but little assistance would be necessary ; at 3 P. M. the
pains began to be severe, but on again examining, I found but little change,
though the whole accessible parietes of the uterus seemed thinner and
softer than in the morning. After noticing the effect of a pain or two, as
another was coming on, I pressed the end of my finger firmly into the
shallow depression, so as to present the edge of the nail to its bottom,
aiding its effect with a slight scratching and boring motion. In a few se-
conds the finger passed through to the niembranes, and the os uteri rapidly
dilated to the size of half a dollar. The labour terminated favourably about
7 P. M., and the mother’s getting up was speedy and favourable.

Case of Club-foot treated by division of Tendo Achillis. — By Thos.
J. Garden, M. D. of Wylliesburg, Va.

I was consulted in August last, by the parents of a child with a horrid
deformity of the left foot which had existed from birth. The big toe of the
foot pointed inwards to the instep of the opposite foot, the heel pointed out-
wards, the sole of the foot looked directly backwards, and the child rested
in walking on the malleolus externus and outer edge of the foot. About
this time a series of successful operations by Dr. Detmold, of New York,
appeared in your journal, a careful perusal of which satisfied me at once of
the success of the operation and of its easy performance. I did not hesi-
tate to advise an operation and to hazard an opinion favourable to its suc-
cess. The child was then about nineteen months old, with a manifest and
striking disparity in the size of the foot and leg, both being smaller than
the opposite or perfect limb. '

On the 26th of September the tendon was divided in the presence of
Doctors Wilson and Bouldin, in the following manner : The child was

placed on its face on a bed, the foot was flexed by an assistant while he
pinched up the skin between the thumb and fore finger, immediately over
the tendon, between one and two inches above its insertion, A narrow sharp
pointed instrument was then passed through the skin with its edge towards
the tendon and immediately in contact with it. As was designed it was
■withdrawn and the tendon divided v*^ith a scalpel, with a convex edge, leav-
ing the cutaneous wound on one side about one quarter of an inch long, and
about one sixth of an inch on the other side. The tendon separated w’ith
a. distinct snap, like the breaking of the tenor string of a musical instru-
ment.

When the thumb and finger were removed, and the skin allowed to re-
sume its original position, the cutaneous wounds had separated an inch or

22*

258

Progress of the Medical Sciences,

more and were immediately opposite the tendon on either side. The
whole was the work of a few seconds only, and was done much to the
satisfaction and gratification of Doctor Bouldin whose zeal had caused him
a ride of twenty-five miles to witness it.

The cutaneous wounds were dressed with common court plaster, and
the limb and foot put up in a roller with a splint in front, made of a bit of
sole’ leather. No bleeding, no swelling, or inflammation or any other cir-
cumstance supervened to jeopard the success of the operation. In forty-
eight hours the cutaneous wounds had healed, the extensible cicactrix had
formed, and an instrument previously prepared, designed to fulfil the indi-
cations in the case was applied. The extension was gradual and perpetual.
In six weeks the child, with the aid of a common boot, split open in front
to fiicilitate the introduction of the foot, was able to run about the room on
the flat sole of a straight foot. When freed from all restraint there was a
tendency in the toe to turn a little inward, but it seemed to be as much
an affair of habit as an abnormal stale of the parts, as some degree of vio-
lence in handling the foot caused not the slightest indication of pain or
uneasiness on the part of the child. A few days after my last visit (six
weeks after the operation) the parents moved to the State of Tennessee. —
Neither of them expressed a fear or a doubt about the final and perfect
relief of the child, from the use of the boot alone, and many who had seen
the foot previous to the operation, and had merely heard of the circum-
stance, doubted the possibility of the fact that the foot had been straightened
and the sole brought down flat upon the floor. The child was in fine health
and I have no doubt a speedy and full developement of the limb and foot
will ensue.

New Vaccine Vims. — We mentioned in our preceding No. (p. 516,) that
Mr. Estlin of Bristol, had obtained vaccine virus directly from the cow —
and had transmitted some lymph propagated from it, to this country. We
have since been favoured by our friend Dr. J. Carson, with lymph from
this source, said to be but fourteen removes from the cow, and have used
it in several instances. The disease which resulted had the peculiar cha-
racters, described by Jenner, but more strongly marked than we have seen
them from the matter at present in use. The inflammation did not make
its appearance until somewhat later than usual, (the fifth day,) but the ves-
icle was regular in its progress, rather larger perhaps than common, but
flat and indented in the centre. The scab was thick, dark-coloured and
firm — more strongly characteristic of the disease than any scab we have
seen for a number of years.

Report of Thomas Lawson, M.D., Surgeon General of the United States Jlrmy,-^
The annual report of the Surgeon General, with a copy of which we have been
favoured by the author, is an interesting document.

The number of cases of indisposition under treatment by the ofiicers of the
medical staff of the army, between the 30th of September, 1837, and the 30th of
September, 1838, is stated to have been 26,053, of which 24, 618’were new cases.
Of the whoie number reported sick, 24,212 have been restored to duty; 473 have
been discharged the service; 29 have deserted; 311 have died; leaving on the
30th of September, 1831, 1,028 on the sick report, of which number 555 were
convalescent.

The following table exhibits the prevalent diseases and their respective mor-
tality.

American Intelligence. 259

Diseases.

No. of Cases.

No. of Deaths.

Diseases.

QJ 1

t.-.

12;

No. of Deaths.

Fevers, Intermittent

3641

Epilepsy

Do. Remittent

898

Gonorrhoea

348

Do. Typhus

Syphilis

179

Do. Inflammation

352

VVounds

1597

Bronchitis

113

Ulcers

oil

Gastro Enteritis

142

Luxations

Pneumonia

224

Fractures

Phthisis

Sprains and contusions

300

Catarrh

1992

Hernia

107

Pleurisy

■

242

Scorbutus

161

Cholera

146

Ascites

Cynancho

285

Apoplexy

Ophthalmia

310

Sequelae of Intemperance

392

Hepatitis

1017

All other slight indispositions

4252

1 Q riro r|

3610

X^lari iJLcd. •

Dysentery

2889

Total.

24,608

311

Colic

1 315

“ The proportion of sick to the number of persons in the military service,”
Dr. Lawson says, “ cannot be ascertained as that number varied so frequently
in tbe year, by the discharge of one body of troops, and the admission into the
service of new levies of militia and volunteers; nor is the proportion of deaths to
the number of sick so absolutely known as might be desired, for the reason that
during active operations in the field many of the cases of indisposition were not
recorded, while it is to be presumed that the deaths have been accurately stated.
Enough, however, has been ascertained from the returns to show that not more
than one in eighty-three of the cases reported (a fraction less than one and a
quarter per cent.) terminated fatally; and thus to prove that the success of the
military surgeons in the treatment of diseases bears a favourable comparison
with the results of the practice of medicine in civil life.”

‘•The law requiring an examination of all candidates for appointment in the
medical staff before admission into the army, has been,” it is stated, “ rigidly
carried out, and the same useful results as heretofore have been realized.”

The following compliment is, we have no doubt, merited.

“ Delicacy,” observes the surgeon general, “perhaps forbids my saying much
in commendation of the medical staff of the army; yet I may be permitted to ex-
press the belief, that (with two or three exceptions) no officers of the Government,
whether of the civil or military department, are more zealous in the cause of their
country, more prompt to obey orders, or more faithful in the discharge of their
various duties. This opinion, I am happy to state, is in accordance with that
very generally expressed by their associates in arms, of the line of the army. Jn
truth, we have now an efficient corps of talented and experienced medical officers;
and as the inducements to enter the army are much greater than heretofore, and
the bar to admission into the service without merit is, through the action of the
medical boards, complete, we may reasonably calculate on introducing into the
army, in each succeeding year a portion of the very elite of the profession.”

Malignant Pustule. — The Southern Medical and Surgical Journal, for Feb-
ruary last, contains a very good paper on this disease by Dr. Wm. M. Car-
penter, Professor of Chemistry and Natural History in the College of Louisiana,
at .Tackson. Dr. Carpenter states that malignant pustule is met with in nearly
every part of the State of Louisiana, and he relates eight cases selected from
many occurring in his immediate vicinity. Three of these cases were fatal.

260 American Intelligence,

Osteo-Sarcoma, and Excision of a large portion of the Lower Jaw, By Dr.
J. Wort, of Jackson county, Indiana. — The subject of this case is Mr. Gerardus
Ryker, of Jefferson county, la., aged 71 years. He is a man of good habits, and
has always enjoyed good health, except an attack of white swelling in both legs,
about the time of puberty.

“About two years ago, he received a severe contusion on the inferior maxillary
bone, by the falling of his horse on the ice, which he thought at the time, had
fractured the jaw. In a few days he recovered from this injury, and had forgotten
the circumstance till about five months afterwards, when he was seized with
most excruciating pain, attended with violent inflammation and swelling of the
jaw. This subsided after a few days, by the use of the topical vapour bath, leav-
ing a knot about the size of a small bullet, on the exterior surface of the right
side, midway between the centre of the chin and the angle of the bone, appa-
rently immovable. This continued to increase gradually, with occasional
paroxysms of severe inflammation, and excruciating pain, till about six months
since, when the pain became continual and lancinating, frequently producing
severe spasms, with continued fever and constipated bowels. The tumour
meanwhile rapidly increased ; he had consulted many surgeons, but they all
considered his case as hopeless.

“In January last. Dr. W. Davidson, of Madison, a graduate of Edinburgh, and
a gentleman of fine medical acquirements, was attending to his case. I was
written to by the Doctor for my opinion and advice, and shortly afterwards was
called on to see the patient. I visited him on the 19th of January, they having
put off calling on me for some time after receiving my answer to Dr. Davidson’s
letter, believing him to be in a dying condition.

“I found him very feeble, emaciated, and haggard in his appearance, but he
became much animated, and joyful on my arrival ; so great was his anxiety, and
strong his hopes that I would operate on him and give him the only remaining
chance of life, or terminate his protracted and insupportable sufferings.

“ The tumour was an enlargement of the inferior maxilla, and a change or soft-
ening of its substance ; the enlargement extended from the neck of the condyloid
process to the centre of the chin, on the one hand, and up to the zygomatic pro-
cess of the malar bone, on the other. From the right ear it reached to within
one inch to the left of the trachea, projecting outwardly nearly two inches, and
inwardly under the tongue to near the centre of that organ. Below, it involved
the throat, pushing the hyoides three-fourths of an inch down to the left side,
and compressing the external carotid artery to near its union with the internal
carotid. It interrupted his speech, deglutition, and respiration very much, so
that at times he was threatened with immediate suffocation.

“ I waited till next morning to deliberate on the matter, and from his strong
entreaty and perfect resignation to the result of an operation, I concluded to per-
form it the next day. I therefore called on Doctors Davidson and Hall, of Madi-
son, la., to assist in the operation. Having premised a gentle aperient the night
before, and given him a grain of morphine half an hour previous to the operation,
he was laid on a table with his head near a window, with a mattrass under him.
I stood on his right side, and one assistant on each side of the table, provided
with nothing more than an ordinary pocket case of instruments, sponge, water,
&c. I commenced the incision by cutting down to the solid tumour, extending
from the tragus of the ear to within one inch of the centre of the chin, being as
far as the tumour reached in that direction. Another incision decussated the first
at right angles, each being seven inches long, being just the diameter of the
tumour. I then carefully dissected the skin from over the tumour, in four angular
flaps, cutting as close as possible to the skin, leaving all muscles &c., with the
flaps. I then began to dissect the tumour from above, near the malar bone, keep-
ing close to the tumour. Inwardly, there was nothing but the lining membrane
of the cheek left, as the teeth were all gone. I next cut through the jawbone at
the chin, and found it (as I had anticipated) soft and brittle. I next dissected out
the process of the tumour which extended under the left side of the throat and

American Intelligence*

261

over the trachea. T had frequently to stop to restrain the hemorrhage. The
small vessels were generally secured by torsion, and the wound cleansed of
blood, and the discharge from minute vessels restrained by the application of a
solution of kreosote, one part to fifty of water, (an application which I use in
many surgical cases to advantage.) I now dissected the tumour from the carotid
artery and jugular vein ; the principal part of the parotid gland being involved
in the tumour, it had to be removed. Dissecting round and leaving the principal
branch of the internal maxillary artery and the temporal artery unhurt, I sought
for the inferior maxillary artery and vein, to take them up before they were cut;
the vein was anterior to the artery and very large, being about the size of a tur-
key quill. 1 put a ligature round it close to the tumour, and cut it, to give room
to search for the maxillary artery, but as soon as I cut it, the blood regurgitated
from the jugular vein as thick as a quill, and the patient being much exhausted,
fainted. We then had to restrain the hemorrhage with a sponge, wetted in a
solution of kreosote, till he was resuscitated by proper stimulants. This vein
retracted and could not be secured till the tumour was removed, or part of it at
least. I then at one stroke of the scalpel, took''off so much of the tumour as was
dissected loose, and cut through the maxillary artery, which had been drawn so
far out of its proper place by the tumour, that it retracted as soon as bisected,
and was so contiguous to the carotid, and such a profusion of blood, that secur-
ing these vessels was a most difficult part of the operation. These secured, I
proceeded to dissect out the balance of the tumour with the jaw bone.

“I cut through the bone again at the neck of the condyloid process. The
dissection completed, the wound was washed out with kreosote solution, and
the flaps brought together and secured by the interrupted suture covered with a
fold of patent lint, and surmounted by a plaster of simple cerate, then a compress
of raw cotton to fill the vacancy and keep the integuments in juxta position with
the parts underneath secured with appropriate bandages, and put him to bed and
gave him a little wine and water occasionally. During the operation and after-
wards, we gave him paregoric, hartshorn, and spirits of cinnamon. In three
hours he recovered from exhaustion, and reaction took place with considerable
fever and some hemorrhage. I allayed his fever with cold water, and arrested
the hemorrhage by kreosote solution and a compress. In three days he could
walk about, being free from pain, and able to eat and talk. I left him in charge
of Doctors Davidson and Hall. Hemorrhage took place pretty freely on or
about the eighth day, from rubbing the wound, and probably tearing away some
ligature, but this was even of benefit, as it prevented or restrained all inflammation.

“ I visited him five weeks afterwards, and found him able to walk about the
yard ; with good appetite and spirits, and the wound quite healed up. There is
quite a chasm instead of an under jaw. After all the blood was w'ashed out of
the tumour it weighed three-quarters of a pound. Query, would a strict deplet-
ing course and antiphlogistic treatment with a seton drawn through the tumour
at an earlier period, or taking up the inferior maxillary artery, have succeeded
in arresting the pain and growth of the tumour 1” — West. Journ. of Med and Phys,
Sciences, July, 1838.

Wound of the Stomach.-MV\\Q following “ case of Recovery from a wound
in the Stomach,” related in a recent No. of a cotemporary (Western Joicrn. Med,
and Phys. Sciences, April, 1838,) is almost enough to make one a believer in
destiny. The recovery from the wound is sufficiently surprising, but recovery
after such treatment as the patient was subjected to, is nothing short of mira-
culous. We give the pase in the words of the narrator.

“ An Indian received a stab in Natchez, on the 24th December, 1837. Six
days elapsed before I saw him, during which period he walked to Rodney,
which is thirty miles from Natchez. On the 30th of December I visited him,
and found, upon examination, a wound of four inches long, a little below and
to the left of the scrobiculus cordis. Protruding from the wound, there pre-
sented a tumour, w'hich, upon first view, I thought was a portion of the bowels;

262 American Intelligence.

but upon further inspection, I discovered that it was most probably omentum.
The external surface of this mass was very vascular, and in a state of suppu-
ration, There was so strong a demonstration of sphacelus in the tumour, that I
determined upon its removal by ligature. Accordingly the ligature was drawn
pretty tight about the tumour, close to the abdomen. In a short time after the
application of the ligature I returned, and found him very ill. Incessant vom-
iting, small, rapid pulse, cold and clammy skin, indicated the necessity of re-
moving the ligature. The knife was then resorted to for the removal of the
protruding mass; but upon cutting into it, I found that a portion of the stomach
constituted a part of the tumour. I carefully separated the already dead parts
of the tumour from that which was not in a state of gangrene. In doing so, I
had to remove a portion of the stomach. The stomach was secured by a liga-
ture, and confined within the lips of the external wound. The wound was then
stitched, and dressed with adhesive plaster.

“ On the 31st, I found him prostrated — with cold skin, feeble pulse, nausea,
and constipated bowels. The external wound, and that portion of the stomach
which was perceptible through the wound, were considerably inflamed, but of
a healthy aspect. Ordered him a solution of Epsom salts, with spirits nit.
dulc. and tinct. opii camph.

January 1. — Some fever to-day, with nausea; his bowels were opened by
the solution which he took yesterday. The external wound is suppurating.
The edges of the wounded stomach very red, with slight suppuration.

“ 2d — Free suppuration from the wound — appearances of granulation upon
the thickened edges of the wounded stomach.

“ On the 5th of January, the ligature which secured the stomach came away.
There is a firm adhesion of the stomach to the peritoneum along the wound.

“ loth. — The wound in the integuments nearly closed by granulations. He is
recovering rapidly; appetite is good, and bowels regular. On the 15th of Jan-
uary, he rose from his bed, the wound being almost entirely cicatrized; his ap-
petite, digestion, and other functions of nutritive, as well as animal life, in a
normal state.”

Dr. S. ^ G. H. White’s Lunatic Asylum at Hudson^ Nev) York.< — We learn
that during the year 1838, ninety-eight patients have enjoyed the benefits of this
institution. Sixty have been admitted during the year, and thirty-eight were
remaining at the close of 1837.

The whole number of recent cases, - - - 30

“ chronic “ - - - 65

“ intemperate - 3

Of the recent cases, 15 recovered, 5 convalescent, 5 improving,

1 unimproved, 4 died, ------ 30

Of the chronic cases, 9 recovered, 6 convalescent, 21 much im-
proved, 15 improving, 10 stationary, 4 died, - - - 65

Intemperate, 2 reformed, 1 unreformed, - - - - 3

Remaining, January 1, 1839, 43 patients, to wit: — Chronic cases S3, recent
do. 10.

Since the opening of this institution, a period of eight years and a half, four
hundred and ten patients have been admitted.

Family worship has been continued during the past year, daily, with bene-
ficial effects, which all the quiet patients have the privilege of enjoying.

Massachusetts General Hospital. — We have before us the Annual Report of
the Board of Trustees of this very useful Institution, for the year 1838.

The number of patients admitted from January 1, 1838 to January 1, 1839,
was as follows:

American Intelligence,

263

Males,

153,

Females.

.52,

Total,

205

24,

18,

. a

48,

85,

133

225

155

380

Males,

107,

Females,

67,

Total,

174

((

226

158

384

Patients paying board,

Do. do. do. part of time,
Do. entirely free,

Discharged during the same period-
Well,

Much relieved,

Relieved,

Not relieved,

Died,

Eloped,

Unfit,

Proportion of deaths to whole number, 1 in 11.

The average population was 43.2.

The average foreign population 15.1.

The average stay of ward-paying patients, about 3 4-5 weeks; that of free
patients, about 5 7-8 weeks.

Of the free patients, more than one-third were female domestics, and rather
more than one-sixth labourers, of whom one-half were Irish.

The weekly cost of supporting each patient was ^5 38.

The able physician and superintendent of the McLean Asylum reports that
the whole number of patients remaining in the house at the commencement of
the year 1838, was —

There have been received during the year,

Total enjoying the benefits of the Asylum,
During the year have been discharged —

Total. Males.

Rec6vered, 74 46

Much improved, 2 2

Improved, 7 4

Not improved, 13 5

Died 12 6

Eloped, 0 0

Unfit, 2 1

After insufficient trial, 21 6

Total discharged, 131 70

Remaining, Jan. 1, 1839, 58

The following is the proportion of recoveries: —

Of all the recent cases discharged, - - -

Of all old cases, - - -

Of all cases, recent and old, -

Of recent cases, exclusive of those who have died, or have
been prematurely removed, - - - -

Of old cases, exclusive, &c. - - - -

Of all cases, exclusive, &c. - - - -

Males.

Females.

Total.

138

128

224

Recent cases,
i, e. of under

Old

1 year before

Females.

cases.

admission.

Total,

78 1-8 per cent.
28 “

56 “

100 • “

40 »

75 1-2 “

Of the class reported as having had an insufficient trial, 10 were much im-
proved, 7 were improved, and 4 were not improved at the date of their dis-
charge.

Dr. Bell confidently believes that almost all these would have been restored,
had it been in the power of friends to have given them an adequate trial.

264

American InteHigence.

Philadelphia Medical Society. By request we insert the following: —

Extract from the minutes of the Philadelphia Medical Society.

Resolved^ That ail discoveries or improvements in medicine or surgery should
be freely promulgated through the appropriate channels of medical information
for the advancement of medical science and for the good of mankind, and that
the appropriation of such discoveries or improvements by their authors, to their
exclusive pecuniary emolument by the taking out of Patents or otherwise, is at
variance with those principles of liberality and beneficence which should distin-
guish the medical character.

Ordered to be published; 27th March 1839.

HENRY KEIM Jr., Rec. Secretary.

University of Pennsylvania. — Four hundred and two medical students matri-
culated in this school the past session. The number of graduates was 158.

Transylvania University. — The number of students in the Medical De-
partment of Transylvania University during the session 1838 — 39 was 211, and
at a commencement held on the 11th March, 1839, fifty-one received the degree
of Doctor of Medicine.

This school has been recently endowed by the councils of the city of Lex-
ington with the sum of forty-five thousand dollars, which will be appropriated
to the erection of a new Hall and to the increase of the Library, apparatus and
anatomical preparations, &c.

It affords us extreme pleasure to record this example of liberality, which
stands out in strong contrast with the mean, trading spirit displayed by the
council of another school. (See preceding No. of this Journal, p. 524.)

University of Maryland. — The cause of the Regents of this University
ns. the Trustees, has been decided by the Court of Appeals in favour of the
former. The Medical Department must consequently be reorganized.

Dartmouth College. — From the catalogue of the officers and students of
this college, issued in September last, it appears that the number of medical
students at that time was 78.

Medical College of Georgia. — The class the past session numbered 60, and
at the commencement held 2d March, 1839, twelve were graduated doctors in
medicine.

Geneva College. — The number of graduates in Medicine in this college was
in 1835, six; in 1836, eight; in 1836, five; in 1838, seventeen.

Louisville Medical Institute. — The catalogue of the class during the session
of 1838—39 shows the number of students to have been 120.

New Works. — Mr. George Adlard, of New York, announces as preparing
for publication “Medical and Physiological Commentaries by Marty n Paine,
M. D.;” also a translation by Dr. Stewart, of the work of Dr. Berton, on the dis-
eases of children, from the period of dentition to puberty.

265

QUARTERLY MEDICAL ADVERTISER.

In consequence of the extended circulation of the American Journal of the
Medical Sciences, the Proprietors intend, in compliance with the wishes of
many of their friends, to prefix to each No. a Sheet of Advertisements. All
Booksellers, Medical Gentlemen, and others desirous of taking advantage of this
mode of announcement, will please address their Advertisements to Lea &
Blanchard, Philadelphia, by the 10th day of the month preceding that of
the publication of the Journal, viz : on 10th July, 10th October, 10th January,
and 10th April.

For one page, ------ Six dollars.

Half a page, or less, ------ Three dollars.

UNIVERSITY OF PENNSYLVANIA.

MEDICAL DEPARTMENT.

The Lectures commence annually on the first Monday of November, and con-
tinue until the ensuing March.

Theory and Practice of Medicine^
Institutes of Medicine^

Special and General Anatomy,
Materia Medica and Pharmacy,
Chemistry,

Surgery,

Obstetrics and Diseases of Women and
Children,

By Nathaniel Chapman, M. D.
By Samuel Jackson, M. D.

By William E. Horner, M. D.
By George B. Wood, M. D.

By Robert Hare, M. D.

By William Gibson, M. D.

By Hugh L. Hodge, M. D.

Clinical Medicine and Surgery taught by the prescribing Medical Officers at
the Blockley Hospital, under the Guardians of the poor, and at the Pennsyl-
vania Hospital.

W. E. HORNER, M. D.

Dean of the Medical Faculty,

MEDICAL COLLEGE

STATE OF SOUTH CAROLINA.

The annual course of Lectures of the Medical College of the State of South
Carolina, will commence on the second Monday of November.

J. Edwards Holbrook, M. D„ Professor of Anatomy,

John Wagner, M. D.,

S. Henry Dickson, M. D.,
James Moultrie M. D.,
Thomas G. Prioleau, M. D.
C. M. Shepard, M. D.,
Henry R. Frost, M. D.,

E. Geddings, M. D.,

F. WURDEMANN, M. D.,

Professor of Surgery,

Professor of Institutes and Practice of Medicine*
Professor of Physiology,

Professor of Obstetrics,

Professor of Chemistry,

Professor of Materia Medica.

Professor of Pathological Anatomy and Medical
Jurisprudence,

Pemonstrator of Anatomy,

SAMUEL HENRY DICKSON, M. D.,

Dean of the Faculty

No. XLVIL—May, 1839.

266 Quarterly Medical Mvertiser,

UNIVERSITY or PENNSYLVANIA.

At a Public Commencement, held April 5th, 1839, in the Musical Fund Hall,
Locust Street, the De^ee of Doctor of Medicine was conferred by the Rev.
Provost, John Ludlow, D. D., upon the following gentlemen : after which an
Address was delivered by N. Chapman, M. D., Professor of the Practice of
Medicine.

NAMES.

RESIDENCE.

SUBJECT OF ESSAY.

Adams, Seth S.

Florida,

Circulation.

Alden, Jatnes M.

New York,

Strictures of the Rectum.

Alston, James W.

North Carolina,

Remittent Fever.

Baker, Charles S.

Pennsylvania,

Dyspepsia.

Bard well, Brainard

Mississippi,

Rubeola.

Bascome, Daniel B.

Turk’s Island,

Peritonitis.

Bayles, Geo. W.

Kentucky,

Reciprocal influence of the
mental and organic man.

Beasley, James A.

Virginia,

Gastritis.

Bellamy, John D.

North Carolina,

Hysteria.

Bieber, William S.
Blunt, Angus F.

Pennsylvania,

Leucorrhoea.

Virginia,

Bilious Colic.

Boisseau, James P.

Virginia,

Acute Dysentery.

Bourgeat, Joseph B.

Louisiana,

Fever.

Bradford, Charles M.

New York,

Yellow Fever.

Brooks, William D. F.
Broughton, Charles H.

New Jersey,

Dysmenorrhoea.

Virginia,

Neuralgia.

Burns, Robert

Pennsylvania,

Physiology and Pathology of
the Stomach.

Carson, James G.

Mississippi,

Pennsylvania,

Hepatitis.

Chambers, George W.

Cholera Infantum.

Cheshire, John S.

Kentucky,

Animal Heat.

Christian, William W.

Virginia,

Chimaphila Maculata.

Cochran, William A.

Alabama,

Syphilis.

Cock, Thomas F.

New York,

Pneumonia.

Collins, J. Milton

New York,

Insanity.

Constable, Thomas F.

Virginia,

Amenorrhma.

Cooper, Richard M. Jun.

New Jersey,

Colitis.

Crichton, James E.

Virginia,

Hydrophobia.

Criddle, Edward F.

Virginia,

Measles.

Cross, William

Virginia,

Spinal Irritation.

Daniels, Ezekiel

Pennsylvania,

Injurious influence of tight dress.

Dibrell, James A.

Tennessee,

Pneumonia.

Donoho, Richard A.

North Carolina,

Amaurosis.

Dortch, Lewis J.

North Carolina,

Arthritis.

Dove, George M.

District of Columbia,

Scarlatina.

Dove, James

Virginia,

Dyspepsia.

Downey, John A.

North Carolina,

Quinia.

Eaton, Samuel W.

North Carolina,

Creosote.

Embree, George W.

New York,

Revulsion,

English, Th. Dunn

Pennsylvania,

Phrenology.

Eppes, Peter

Virginia,

Erysipelas.

Evatt, William H.

Canada,

Pleuritis.

Fountleroy, S, Griffin

Virginia,

Dysentery.

Fell, Jonathan

Pennsylvania,

Pericarditis.

Fox, Daniel J.

South Carolina,

Dysentery.

Frayser, Benjamin F.

Virginia,

Diseases of Dentition,

Garland, W. P.

Virginia,

Hepatitis.

Gilmer, Francis W.

Virginia,

Arthritis.

Given, Robert A.

Ireland,

Fractures.

Graves, Nathaniel S.

-North Carolina,

Gastritis Acuta.

Griffin, Charles M.

Georgia,

Virginia,

Hydrophobia.

Griffin, James L. C.

Diseases of the Osseous System.

Haines, William S.

Delaware,

Colica Pictonum.

Hamilton, James S.

Georgia,

Puerperal Convulsions.

Quarterly Medical Advertiser.

267

NAMES.

RESIDENCE.

SUBJECT OF ESSAY.

Hartman, William D.

Pennsylvania,

Menstruation.

Haskins, Richard E.

Virginia,

Pestis Orientalis.

Hawkins, Peter B.

North Carolina,

Gastritis.

Heaton, James D.

Virginia,

Trachitis.

Henry, Samuel H.

Maryland,

Club-foot.

Hill, William A.

Virginia,

Medicina.

Holden, Levi H.

Rhode Island,

Blood-letting.

Hudson, Edward

Pennsylvania,

Infantile Dentition.

Hughes, John S.

Virginia,

Scarlatina.

Hunter, Alexander

Georgia,

Evidences of general poisoning.

Hussey, Elijah M.

Alabama,

Position and Countenance.

Irwin, William F.

Pennsylvania.

Dropsy.

Johnson, John G.

Georgia,

The means of lessening the
pains of Parturition.

Jones, Alexander

Maryland,

Resuscitation.

Jones, Randolph M.

Maryland,

Passions.

Kerr, James W.

Pennsylvania,

Cerebral symptoms connected
with diseases of the alimen-
tary canal.

Klapp, Joseph Jun.

Pennsylvania,

Fungus of the Testicles.

Larimore, James S.

Ohio,

District of Columbia,

On the color of the Skin.

Laurie, Shepherd

Medicine an elevated Science.

Lawrence, Thomas C.

Mississippi,

Yellow Fever.

Lea, James M.

North Carolina,

Dysentery.

Long, Crawford W.

Georgia,

Functional Amaurosis.

Lyle, William J.

Virginia,

Epilepsy.

Mackenzie, James S.

Maryland,

Croup.

Marthens, Henry C.

Pennsylvania,

Empyema.

Marr, John H.

Alabama,

Acute Gastritis.

Massenburg, William A.

Virginia,

Syphilis.

Mason, Robert H.

Virginia,

Acute Gastritis.

Maynard, Joseph P.

Barbadoes,

Nervous Asthenia,

McKee, Alexander R.

Kentucky,

Puerperal Peritonitis.

McKee, William H.

North Carolina,

Puerperal Madness.

Mershon, Sumpter

Mississippi,

Congestive Fever.

Millan, Lyle

Virginia,

Remittent Fever.

Middleton, Benjamin S.

Virginia,

Blood-letting.

Mitchell, Bruce H.

Alabama,

Auscultation of the Heart.

Mitchell, Moses T.

Pennsylvania,

Acute Dysentery.

Moore, James J.

North Carolina,

Intermittent Fever.

Moore, Edward W.

Louisiana,

Mercury.

Mosely, Thomas H.

Georgia,

The Mind as the result of Physi-
cal Organization.

Nelson, William A.

Virginia,

North Carolina,

Urinary Calculi.

Norcom, Caspar W.

Phrenitis.

Oliver, James L.

North Carolina,

Proto-chloride of Mercury.

Page, William B.

Virginia,

Scarlatina-

Paschall, Zebulon M.

North Carolina,

Opium.

Patterson, George W.

Philadelphia,

Iodine.

Peacock, Howell

Georgia,

Remittent Fever.

Pegram, William E.

Virginia,

North Carolina,

Angina Pectoris.

Pittman, Newsom J.

Bronchitis.

Pleasants, William B.

Virginia,

Scrofula.

Pope, Charles A.

Alabama,

Pathology of the Arteries.

Reese, John J.

Philadelphia,

Acute Dysentery,

Reynolds, Marcus

South Carolina,

Phrenitis.

Richardson, John D.

Pennsylvania,

Varioloid.

Ridgely, Henry

Delaware,

Lithotripsy.

Ridley, William M. S,

North Carolina,

Calandra Granaria,

Rives, Henry W.

Rhode Island,

Erysipelas.

Rives, William H.

Virginia,

Qualifications of a Surgeon.

Robards, Henry J.

North Carolina,

Pneumonia.

268

Quarterly Medical Mvertiser,

Roberts, William R.

Virginia,

Pleurisy.

Robeson, Andrew Jun.

Massachusetts,

Intermittent Fever.

Sappington, Thomas

Maryland,

Chronic Hepatitis.

Scott, Thomas F.

Virginia,

Amenorrhoca.

Shackelford, John

North Carolina,

Ramollissement.

Sims, Richard S.

Virginia,

North Carolina,

Rubeola.

Smallwood, Thomas J. P.

Acute Gastritis.

Smith, Edward G.

Philadelphia,

Traumatic Tetanus.

Spalding, Joshua A.

Maine,

Cholera.

Speece, J. Morton

Virginia,

Phrenitis.

Spence, William A. Jun.

Virginia,

Secale Cornutum.

Stamps, William L.

Arachnitis.

Stokes, Thomas D.
Stone, James B.

North Carolina,

Delirium Tremens.

Virginia,

Ventriculus Stomachus.

Swanson, William G.
Swartz, Benj. Franklin

Georgia,

Puerperal Peritonitis.

Pennsylvania,

Haemoptysis.

Talley, Horace A.

Virginia,

Dysentery.

Taylor, James Theus

Alabama,

Eupatorium Perfoliatum.

Taylor, John E.

Philadelphia,

Cholera Infantum.

Taylor, Lyttleton L.

Florida,

Puerperal Peritonitis.

Taylor, James McDowell

Virginia,

Pathology of Cellular Tissue.

Tuggle, Richard B.

Virginia,

North Carolina,

Menstruation.

Tull, John G.

Amenorrhcea.

Trevor, M. Randall

Pennsylvania,

Menstruation.

Vedder, Alexander M.

New York,

History of the Epidemic Rubeo-
la, and as it prevailed at the
Children’s Asylum of Philadel-
phia, in the summer of 1838.
Causes of Inflammation.

Vinson, Daniel S.

Louisiana,

Walker, John

Virginia,

Tracheitis.

Watkins, Clement C.

Virginia,

Intermittent Fever.

Wendel, James E.

Tennessee,

Blood-letting as a Therapeutic
Agent.

Phthisis Pulmonalis.

Whaland, Thomas H.

Maryland,

Williams, Robert D.

North Carolina,

Tetanus.

Wilkinson, Joseph B.

Louisiana,

Anatomy of and operation for
Inguinal Hernia.

Wood, John P.

Virginia,

Asthma.

Wood, Thomas

Ohio,

Hydrated Peroxide of Iron.

Yohe, Andrew

Pennsylvania,

Aneurism.

At the Collegiate Commencement, held July 13th, 1838, the following gen-
tlemen also received the Degree of Doctor of Medicine.

George F. Boisseau,
Charles R. Dodson,
Augustus C. Evans,
Charles Foulke,

Thomas Glaskin,

Amos W. Griffiths,

John Miner,

Robert M. McClure,
Charles J. Pleasants,
Thomas Mawney Potter,
John Howard Smith,
John A. Smith,

Total, 158.

Virginia,

North Carolina,

Pennsylvania,

Virginia,

Pennsylvania,

Maryland,

Indiana,

Virginia,

Rhode Island,
Pennsylvania,
Tennessee,

Acute Gastritis.

Acute Peritonitis.

Acute Dysentery.
Belladonna in Pertussis.
Vis Med. Naturee.
Intermittent Fever.
Acute Hepatitis.
Intermittent Fever.
Rubeola.

Rubeola.

Ligature of the Aorta.
Menstruation,

W. E. HORNER, M. D.

Dean of the Medical Faculty.

Quarterly Medical Mdvertiser.

269

T© THE aEDISAt FASULTir.

The subscriber having' for many years prepared several valuable extracts, which
have received the approbation, and been extensively used by the most eminent physi-
cians in various parts of the United States, deems it his duty to caution the public
against an attempt now making to impose on them an article prepared by a certain
John Hughes, who alleges that he for several years prepared the articles while in the
employ of the subscriber. The assertion is utterly untrue, as the said Hughes was
employed merely as a porter and labourer about the store. The bottles, directions, and
wrappers are imitations of those used by the subscriber, and impudently pretends that
the signature of John Hughes is as true a test of the genuineness of the preparation as
his own. Frequent attempts have been made by others to imitate articles prepared by
the subscriber, which he has invariably treated with contempt ; but the present one is
so shameless that he deems it his duty to those who have used and relied on the excel-
lence of his preparations to expose the imposture; and he further apprises them that it
is his intention to institute legal proceedings against all concerned in the measure.

GEO. W. CARPENTER, 301 Market St. Philadelphia.

GEO. W. CARPENTER’S

Precipitated Extract of Bark, fully equal to the Sulphate of Quinine in the same

Doses,

At One Dollar Per Ounce.

In the November Number for 1838 of this Journal, at page 267, 1 gave a detailed
description of the above Extract. Since then I have received a number of letters from
distinguished physicians in various parts of the United States. I have selected a couple
from the number received, a copy of which I beg leave to annex.

Extract of a Letter from Dr. A. W. Washburn of Manchester, Mississippi.

Manchester, Miss. January 21, 1839.

Dear Sir: — I am sorry to find that so valuable an article as the Sulphate of Quinine
has become so scarce, but am satisfied that your precipitated Extract of Bark will
supply the desideratum occasioned by its deficienc3^ I confess I should not like to do
without Quinine altogether, as there are some cases of disease attended with such ex-
treme irritability of the stomach as to make it from the minuteness of the dose, more
eligible than any other tonic of the same class.

1 have used your Precipitated Extract of Bark, and found it equal if not superior to
the Sulphate of Quinine in intermittents. Indeed I can say of this Extract of Bark,
what I cannot of Quinine, viz: that I have never failed with it to effect a cure of inter-
mittent fever where it was eligible. I remain, with respect, yours.

To Mr. Geo. W. Carpenter. A. W. WASHBURN.

Extract of a Letter from Dr. Alexr. H. Innes.

Claysville, Kentucky, February 20, 1839.

Dear Sir : — I avail myself of this opportunity of communicating to you the effect of
your Precipitated Extract of Bark in the treatment of intermittent fever. I used eight
ounces of it in my practice last fall, and found it the most efficient article in the treat-
ment of intermittent fever (Quinine not excepted) that I have ever been able to procure,
nineteen-twentieths of the cases yielded to it in twenty-four hours, and not a solitary
case resisted the use of it for forty-eight hours. It was not attended with one of the
unpleasant symptoms attendant on Quinine in large doses.

My mode of using it was as follows : after cleansing the stomach and evacuating the
bowels to begin six hours before the next paroxysm was anticipated, and give a six
grain pill every two hours until the time had passed for the paroxysm.

For children I prepared the use of the Extract in brandy or proof spirits, in reduced
quantities, say four grains dissolved in four teaspoonfuls of brandy, and one teaspoonful
every two hours, as with the pills in adults. Respectfully yours.

To Mr; Geo. W. Carpenter. ALEXR. H. INNES.

23*

270

Quarterly Medical Advertiser,

Extract of a Letter from Dr. R. Genley.

Saline, Wastenaw Co. Michigan.

Dear Sir : — The Precipitated Extract of Bark which I had of you direct was always
good, and answered the same purpose to me as the Quinine. The last which I bought
however was in New York, through the agency of a friend, who purchased it of a drug-
gist there, and it was a spurious article and worthless ; an ordinary dose of it would
nauseate the stomach without any other sensible effect. Please send me fifty ounces of
your Extract to care of Silas Cook &, Son, New York. I think I can introduce it into
extensive use here, and if I can, shall be happy to do so for your benefit, and for the
benefit of the sick. You would be surprised at the amount of Quinine required here.
To do justice to Michigan diseases, in a practice of three thousand dollars per annum,
thirty or forty bottles are as little as can be used ; fifty or sixty might be to advantage.
Your Precipitated Extract will be a great advantage to us. Yours truly.

To Mr. Geo. W. Carpenter. ROYAL GENLEY.

MBDICINE CHESTS.

Medicine Chests should be made of different sizes, and the contents so proportioned
as to suit the sizes of families and the number of domestics. Another consideration
should be kept in view ; whether residing in the city where a chest can, in a short time
be replenished, or whether in the country where such facility does not exist, and where
of course a larger chest would be required, and the quantity as well as the number of
articles should necessarily be increased.

In order to have chests adapted to all the various conditions of life, I have put up
five sizes of chests of particular description and construction, and denominated them
Carpenters’ Medieine Chests, varying in numbers from 1 to 5, so as to distinguish them
and properly to characterize them according to the numbers — thus ; No. 1 is adapted
for a family residing in the city. No. 2 for a large family in the city or a small family
in the country. No. 3 for a large family at a considerable distance in the country, or
for a plantation where a large number of domestics are employed. No. 4 for a prac-
tising physician, containing a full assortment of medicines, &c. No. 5, for sea, suita-
ble for large vessels and packet ships. These chests will be all filled with fresh and
choice medicines, in ground stoppered heavy flint glass bottles, of various sizes, neatly
labelled in gold, and which will be put at a very moderate price. The following are
descriptions of each chest.

Carpenter’s Medicine Chest, No. 1 :

Adapted for a family residing in the city.

This is a neat Mahogany case, finely finished with brass mountings, lock and key,
handles, &c., and forms a neat and appropriate piece of parlor furniture. On opening
the lid the following bottles are displayed : —

4, Four ounce salt mouth bottles ; 5, two ounce Tincture bottles ; 4, one ounce
salt mouth bottles ; 8, one ounce Tincture bottles, under which is a drawer which con-
tains the following articles : 4, two ounce Fancy Porcelain Jars.

Also in which are neat separate divisions made for, and containing the following
articles:—! Pair of Scales and Weights; Graduated Glass measure; Small Spatula;
Small Glass mortar and pestle ; Small Glass Cup to take doses of medicine from ; Car-
penter’s Medicine Chest Dispensatory, containing a full description of all the Medicines,
and a concise description of the treatment of the diseases.

This chest will cost from $20 to $30, according to the finish, and the variation of the
cost between bottles labelled in gold or in the ordinary manner, and whether also of cut
glass or plain.

Carpenter’s Medicine Chest, No. 2 :

Adapted for a large family in the city or a small
family in the country.

This is also a neat Mahogany Chest, handsomely finished, with brass mountings, lock
and key, handles, &c. On opening the lid the following articles are displayed : —

Quarterly Medical Advertiser, 271

5, Four ounce salt mouth bottles ; 7, two ounce salt mouth bottles ; 5, four ounce
Tincture bottles ; 7, two ounce Tincture bottles ; 8, one ounce salt mouth bottles ;
under which is a drawer containing the following articles: 4, four ounce Covered Por-
celain Jars; 4 Tin Canisters, with lids.

Also, neat and appropriate divisions, containing 1 pair of Scales and Weights ; Gra-
duated Glass Measure ; Small Glass Mortar and Pestle; Spatula; Small Glass Mea-
sure Cup ; 1 Copy Carpenter’s Medicine Chest Dispensatory.

This chest will cost from $30 to $35.

Carpenter’s Medicine Chest, No. 3 :

For a large family residing at a considerable distance in the country or for a planta-
tion where a large number of domestics are employed.

This being a larger chest, is generally made of pine, poplar, or cherry, neatly stained
and varnished, or can be made of mahogany, if desired, at a few dollars more expense.
On opening the lid the following bottles are displayed : —

6, Eight ounce Tincture bottles ; 7, four oCince Tincture bottles ; 10 two ounce Tine-
ture bottles ; 6, eight ounce salt mouth bottles ; 7, four ounce salt mouth bottles ; under
which is a drawer containing the following articles ; 4, half ounce salt mouth bottles ;
6, four ounce canopy Porcelain Jars ; 6, Tin Canisters.

Neat and appropriate divisions, containing Scales and Weights ; Spatula ; Graduated
Glass Measure; Glass Mortar and Pestle; Glass Cup ; Carpenter’s Medicine Chest
Dispensatory.

This chest will cost from $35 to $40.

Carpenter’s Medicine Chest, No. 4 :

Adapted for a practising Physician in the country.

This being a large chest, is generally made of pine, poplar, or cherry, neatly stained
and varnished, or can be made of mohogany, if desired, at a few dollars additional
expense.

This chest contains a neat and general assortment of medicines for a Practising
Physician, and will be found a highly useful article.

On opening the lid, the following articles are displayed at one glance : —

7, Twelve ounce Tincture bottles, containing 01. Ricini, Sp. ^Eth. Nit., Syr. Scillge,,
Sp CamphorsB, Mel. Scillse Com., Tinct. Cinchon. Com., Syr. Rhei ar.

8, Eight ounce Tincture bottles, containing Ess. Menth. Pip., Tr. Opii, Tr. Opii Cam.,
Vin. Antimon., Sp. Cornu. Cervi, Sol. Quinae,, Sp. Lavend. Com., .^ther Sulph.

9, Four ounce Tincture bottles, containing Bals. Copavia, Sp ./Ether. Sul. Com., Tr.
Benzoin Com., Tr. Guaiac, Tr. Assafoetid., Tr. Myrrhae, Tr. Sapon. Com., Tr. Gentian.
Com,, Aqua Plumbi

12, Two ounce Tincture bottles, containing, Tinct. Digitalis, Acet. Opii, Sp. Ammon.
Ar., Vin. Rad. Colchic., Tr. Opii. Narcot. Depr., Acid. S. Arom., Tr. Meloe Vesic., Tr.
Kino, Tr. Cubebse, Tr. lodin., Tr. Rhei, Tr. Valerianae.

14, One ounce Tincture bottles, containing Ol. Anisi, 01. Carui, Ol. Cinnamom., 01.
Caryophil., Ol. Copaiva., 01. Cubebae, Ol. Juniper, 01. Lavindul. 01. Limonis, 01. Menth.
Pip., Ol. Sassafras, 01. Santonic., 01. Terebinth., 01. Sabinae.

14, One ounce salt mouth bottles, containing. Iodine, Potass. Hydriod., Hydrar.
Chlor., Opii Pulv,, Pulv. Antiraonialis, Fol. Digitalis Pulv., Pulv. Nit. Potas., Caryophil.
Pulv., Zinci Sulph,, Cupri Sulph., Pulv. Gallar., Argent. Nitrat., Ferri Sulph., Secale
Cornut.

15, Quarter ounce salt mouth bottles, containing Acet. Morphiae, Sulph. Morphiae,
Piperine, Strychnine, Acid. Prussic, Veratrine, Kreosote, Ol. Croton., Elatine, Proto-
lodur. Mercury, Deuto do.. Iodide of Lead, Lupuline; 01. Cantharid,, 01. pip. Nig.

7, Twelve ounce salt mouth bottles, containing Magnes. Usta, Pulv. Cinchon. Potas.
Bitart., Sulph. Subl., Pulv. Jalapae, Pulv. Rhei., P. Sal. Rochel.

8, Eight ounce salt mouth bottles, containing Pulv. Aloes, Ipecac, pulv., Sodae Bi-
carb., Acid Tartaric., Creta. ppt., Ammon. Carb,, Potas. Carb., Pulv. Zinjib.

9, Four ounce salt mouth bottles, containing Acacise, pulv., Sodae Subbor,, Hyd. Sub.
Mur., Quinae Sulph., Colocynlh pulv., Camphora, Scillae, pulv., Spigeliae, pulv,. Serpen-
tariae pulv.

272

Quarterly Medical Advertiser*

Under which is a drawer containing the following: —

6, Eight ounce canopy top jars, containing Unguent. Hydrarg., Unguent. Res. Fiav.,
Cerat. Simp., Ung. Cantharides, Mass. Hydrarg., Ung. Hyd. Nit.

6, Tin canisters, containing Fol. Sennse, Manna, Magnesiee Sulph., Linteum, Em-
plast. Adhes. Acaciee Gum.

Also, neat and appropriate divisions, containing Scales and Weights, Spatulas — 2
sizes; Glass Mortar and pestle; Wedgwood mortar and pestle; Graduated Glass Mea-
sure; Carpenter’s Medicine Chest Dispensatory.

The above chest will cost from 90 to 100 dollars.

Chest No. 4, intended for Physicians is also made of a very small size suitable for
carrying out in a gig or sulky; the most prominent and important articles are put up in
small quantities, sufficient for each day’s practice. The bottles are neatly put up and
handsomely labelled, price 15 to 20 dollars, according to finish.

Carpenter’s Medicine Chest, No. 5:

, For Sea Voyage.

The above chest is intended for a ship; the size can be proportioned and varied to
suit the vessel, length of voyage, &c.

This being a large chest, is generally made of pine, poplar or cherry, neatly stained
and varnished, with lock and key, brass handles, &c.; it can also be made of mahog-
any if desired, at a few dollars more expense.

On opening the lid, the following articles are displayed, viz: —

7, Twelve ounce Tincture bottles; 8, Eight ounce Tincture bottles; 8, Eight ounce
salt mouth bottles; 6, Four ounce salt mouth bottles; 6, Pint ointment Jars; 4, Two
ounce salt mouths.

Under which is a drawer containing 10, Tin canisters.

Sundry articles — 2 Lancets; 1 pint Syringe; 2 Bougies; 2 Catheters; Scales and
Weights; Composition Mortar and Pestle; Glass Mortar and Pestle; Graduated Mea-
sure; Penis Syringes, 3; Spatulas — 2 sizes; Carpenter’s Medicine Chest Dispensatory.

The prices affixed to the different chests above described include medicines. The
bottles and jars in each will be filled with fresh medicines of the best quality.

GEO. W. CARPENTER,

301 Market Street, Philada.

MEBICAL CONVENTION.

In obedience to a resolution of the Medical Convention of the United States, assem-
bled in Washington City in January, 1830, public notice is hereby given, that a similar
Convention will meet at the National Hotel, in the said city, on the first Wednesday of
January, 1840, for the purpose of revising the Pharmacopoeia of the United States.

Each incorporated State Medical Society, incorporated Medical College, and incorpo-
rated College of Physicians and Surgeons, is requested to elect a number of delegates,
not exceeding three, to attend the said Convention. The several incorporated bodies
mentioned are also requested to submit the Pharmacopoeia to a careful revision, and to
transmit the result of their labours, through their delegates, or through any other chan-
nel, to the next Convention. They are further requested to transmit to the undersigned
the names and residence of their respective delegates, so soon as they shall be appointed,
so that a list of them may be published, for the information of the Medical public, in
the month of October next

By order of the Medical Convention, assembled at Washington, in January, 1830.

LEWIS CONDICT, M. D., President.

Morristown, New Jersey, April 6> 1839.

Quarterly Medical Advertiser,

273

A NEW DICTIONARY

MEDICAL SCIENCE AND LITERATURE.

LEA AND BLANCHARD,

SUCCESSORS TO CAREY CO.,

Will Publish, in the course of the present month,

A NEW EDITION,

Completely Revised, with Numerous Additions and Improvements,

DUNGLISON’S DICTIONARY

MEDICAL SCIENCE AND LITERATURE:

CONTAINING

A CORRECT ACCOUNT

OF THE

DIFFERENT SUBJECTS AND TERMS,

With the Synonymes in Various Languages, Formal for
Officinal and Empirical Preparations, ^c., ^'C,

IN ONE ROYAL 8 VO. VOLUME.

They have Recently Published
A Third Edition, Improved and Modified, of

DUNGLISON’S

HTTMAW PH YSIOLO

Illustraied With Numerous Engravings,

IN TWO VOLUMES.

“We are happy to believe that the rapid sale of the last edition of this valuable work
may be regarded as an indication of the extending taste for sound physiological know-
ledge in the American schools: and what we then said of its merits, will show that we
regarded it as deserving the reception it has experienced. Dr. Dunglison has, we are
glad to perceive, anticipated the recommendation which we gave in regard to the addU

274 Quarterly Medical Advertiser,

tion of references, and has thereby not only added very considerably to the value of
his work, but has shown an extent of reading which, we confess, we were not prepared
by his former edition to expect. He has also availed himself of the additional materials
supplied by the works that have been published in the interval, especially those of Miil-
ler and Burdach. So that as a collection of details on human physiology alone, we do
not think that it is surpassed by any work in our language: and we can recommend it
to students in this country (England) as containing much with which they will not be
likely to meet elsewhere.” — British and Foreign Medical Review, for Jan. 1838.

“ This work exhibits another admirable specimen of American industry and talent,
and contains an account of every discovery in Europe up to the period of a few months
prior to its publication. Many of the author’s views are original and important.” —
Dublin Journal of Medical Sciences, for March, 1839.

ELEMEMTS OF HYGIEME:

On the Influence of Atmosphere and Locality ; Change of Air and Climate, Seasons,
Food, Clothing, Bathing, Sleep, Corporeal and Intellectual Pursuits, ^c.

On Human Health, Constituting Elements of Hygiene,

By Robley Dunglison, M. D., &c., &c.

“ We can recommend this work to the public with the utmost confidence, as one of
the best treatises on the subject we possess.” — American Journal of the Medical Sciences,
February, 1835.

“ It is a book, therefore, interesting to the general reader; and, however popular and
useful may have been the unrivalled work of Dr. Dewees on Children, we hazard little
in predicting that this work will be still more extensively sought and read.” — Boston
Medical Magazine.

“ Professor Dunglison has displayed much judgment and ability in selecting and di-
gesting his materials, and has furnished a better exposition of the elements of Hygiene
than can be any where found in the English language.” — North American Archives for
Medical and Surgical Science, for March, 1835.

THE MEDICAL STUDENT:

OR,

AIDS TO THE STUDY OF MEDiCiNE.

Including a Glossary of the Terms of the Science, and of the
Mode of Prescribing;

Bibliographical Notices of Medical Works;

The Regulations of the Different Medical Colleges of the Union, &c.
BY ROBLEY DUNGLISON, M.D., &c., &c.

IN ONE VOLUME, 8 VO.

“ This is another of those valuable compilations for which the profession in America
is so much indebted to Professor Dunglison.

“ Although chiefly intended for students in the American States, it will be useful for
students in all countries, as it contains a vast deal of that kind of miscellaneous and
varied information which is so constantly needed, yet so difficultly found by them.
Besides the mere technical matter, this volume touches on many subjects of yet higher

Quarterly Medical Advertiser. 275

importance, and among others, on the moral duties and professional conduct of the
medical practitioner, which are laid down clearly and forcibly, and with a just appreci-
ation of the dignity of the office.

“We recommend ‘The Medical Student’ in the strongest terms to bis brethren in
all countries, and in an especial manner to his compatriots.” — British and Foreign
Medical Review^ for October, 1837.

“ This is a useful guide-book for students, containing information which those who
are about to commence the study of Medicine ought to possess.” — American Journal
of the Medical Sciences^ November, 1837, page 276.

OR,

PRINCIPLES OF MEDICAL PRACTICE.

With Tables of the Chief Remedial Agents and their Prepara-
tions^ and of the Different Poisons and
their Antidotes.

Br Robley Dunglison, M. D., &c., &c.

ONE VOLUME, LARGE 8vO.

“There being at present before the public several American works on Therapeutics,
written by physicians and teachers of distinction, it might be deemed unjust in us, and
would certainly be invidious, to pronounce any of them superior to the others. We
shall not, therefore, do so. If there be, however, in the English language, any work of
the kind more valuable than that we have been examining, its title is unknown to us.

“We hope to be able to give such an account of the work as will strengthen the de-
sire and determination of our readers to seek for a farther acquaintance with it, by a
candid perusal of the volume itself. And, in so doing, we offer them an assurance that
they will be amply rewarded for their time and labour.” — Transylvania Journal^ VoL
IX, No. 3. December, 1836.

“ Few writers in our profession have been more industrious than Professor Dunglison,
and fewer still have sustained themselves equally well in the course of so many practi-
cal publications. From the hasty perusal which we have given it, we are inclined to
think that it possesses equal if not superior merit to any which have preceded it from
the prolific pen of its author.

“ It shows the learning and research of its author on every page, and as an eclectic
production it will bear comparison with similar works in any country. We would ad-
vise our readers to purchase and peruse it for themselves.” — Western Journal of the
Medical Sciences, No. XXXVIII, page 252, for September, 1836.

“ The work ought not to be thus hastily dismissed. From an attentive examination
less cannot in justice be said than that, while we find nothing to excite a single captious
feeling, we find every thing to instruct and entertain. Although Dr. Dunglison may be
regarded as a prolific writer, if he produces always such volumes as this, we shall cer-
tainly not think him in danger of the charge of overworking his genius. We must
leave it with the candid advice to every medical man to be soon in possession of this
volume of sound and rich observations in the art he would advance with pleasure, as
well as practise as a duty.” — Boston Medical and Surgical Journal.

mEBICXNS.

The practice of PHYSIC. By W. P.
Dewees, M. D. Adjunct Professor of Mid-
wifery, in the University of Pennsylvania,
2d edition, complete in 1 vol. 8vo.

“ Wc have no hesitation in recommending it as deci-
dedly one of the best systems of medicine extant. The
tenor of the work in general reflects the highest honor on
Dr. Dewees’s talents, industry, and capacity for the exe-
cution of the arduous task which he had undertaken. It
is one of the most able and satisfactory works which mod-
ern times have produced, and will be a standard authori-
ty.”— London Med. and Surg. Journal, ^ug. 1830.

DEWEES ON THE DISEASES of CHIL-
DREN. 6th ed. In 8vo.

The objects of this work are, 1st, to teach those who
have the charge of children, either as parent or guar-
dian, the most approved methods of securing and im-
proving their physical powers- This is attempted by
pointing out the duties which the parent or the guar-
dian owes for this purpose, to this interesting, but
helpless class of beings, and the manner by which
their duties shall be fulfilled. And 2d, to render
available a long experience to these objects of our
affection when they become diseased. In attempting
this, the author has avoided as much as possible,
“ technicality and has given, if he does not flatter
himself too much, to each disease of which he treats.
Its appropriate and designating characters, with a
fidelity that will prevent any two being confounded
together, with the best mode of treating them, that
either his own experience or that of others has sug-
gested.

DEWEES ON THE DISEASES of FEMALES.
6th edition, with Additions. In 8vo.

A COMPENDIOUS SYSTEM OF MID-
WIFERY ; chiefly designed to facilitate the
Inquiries of those who may he pursuing this
Branch of Study. In 8vo. with 13 Plates. 7th
edition, corrected and enlarged. By W. P.
Dewees, M. D.

GENERAL THERAPEUTICS, or Principles of Medici-
nal Administration, with Tables of the chief remedial
Agents, and their preparations, employed in the treat-
ment of Disease. By Robley Dunglisson, M. D., &c,
&c. (in the press.)

MANUAL OF PATHOLOGY : containing
the Symptoms, Diagnosis, and Morbid Char-
acter of Diseases, &c. By L. Martinet.
Translated, with Notes and Additions, by
Jones Quain. Second American Edition,
12mo.

We strongly recommend M. Martinet’s Manual to the
profession, and especially to students; if the latter wish
to study diseases to advantage, they should always have
it at hand, both when at the bedside of the patient, and
when making post mortem examinations.”— ./^iMericaw
Journal of the Medical Science.?, JVe. I.

CLINICAL ILLUSTRATIONS of FEVER,
comprising a Report of the Cases treated at
the London Fever Hospital in 1828-29, by
Alexander Tweedie, M. D., Member of the
Royal College of Physicians of London, &c.
1 vol. 8vo.

In short, the present work, concise, unostentatious
as it is, would have led us to think that Dr. Tweedie was
a man of clear judgment, unfettered by attachment to
any fashionable hypothesis, that he was an energetic but
judicious practitioner, and that, if he did not dazzle his
readers with the brilliancy of theoretical speculations, he
would command their assent to the solidity of his didac-
tic precepts.”— .Wed. Chir. Journal.

The ANATOMY, PHYSIOLOGY, and DIS-
EASES OF THE TEETH. By Thomas Bell,
F.R.S., F.L.S. &c. In 1 vol. 8vo. With Plates.

” Mr. Bell has evidently endeavored to construct a
work of reference for the practitioner, and a text-book
for the student, containing a ‘plain and practical digest
of the information at present possessed on the subject;
and results of the author’s own investigations and expe-
rience.’ '’***“ We must now take leave of Mr. Bell,
whose work we have no doubt will become a class-book
on the important subject of dental surgery.”— .3/edico-CA!-
rurgical Review.

“ We have no hesitation in pronouncing it to be the
best treatise in the English language.” — Worth American
Medical and Surgical Journal, Wo. 19.

AMERICAN DISPENSATORY. Ninth
Edition, improved and greatly enlarged. By
John Redman Coxe, M. D. Professor of Ma-
teria Medica and Pharmacy in the Univer-
sity of Pennsylvania. In 1 vol. 8vo.

This new edition has been arranged with spe-
cial reference to the recent Pharmacopoeias, published
in Philadelphia and New-York.

ELLIS’ MEDICAL FORMULARY. The
Medical Formulary, being a collection of
prescriptions derived from the writings and
practice of many of the most eminent Phy-
sicians in America and Europe. By Benjamin
Ellis, M. D. 3d. edition. With Additions.

” \Ye would especially recommend it to our brethren in
distant parts of the country, whose insulated situations
may prevent them from having access to the many autho-
rities which have been consulted in arranging the mate-
rials for this work.” — Phil. Med. and Phys. Journal.

MANUAL OF MATERIA MEDICA and
PHARMACY. By H. M. Edwards, M. D.
and P. Vavasseur, M. D. comprising a con-
cise Description of the Articles used in
Medicine ; their Physical and Chemical
Properties ; the Botanical Characters of the
Medicinal Plants ; the Formula; for the Prin-
cipal Officinal Preparations of the American.
Parisian, Dublin, &c. Pharmacopoeias ; with
Observations on the proper Mode of combin-
ing and administering Remedies. Trans-
lated from the French, with numerous Ad
ditions and Corrections, and adapted to the
Practice of Medicine and to the Art of Phar-
macy in the United States. By Joseph Tog-
no, M. D. Member of the Philadelphia Med-
ical Society, and E. Durand, Member of the
Philadelphia College of Pharmacy.

“ It contains all the pharmaceutical information that
the physician can desire, and in addition, a larger mass of
information, in relation to the properties, &c. of the dif-
ferent articles and preparations employed in medicine,
than any of the dispensatories, and we think will entirely
supersede all these publications in the library of Ihephy
sician." — Am. Journ. of the Medical Sciences.

A TREATISE ON PULMONARY CONSUMP-
TION, comprehending an Inquiry Into the Cause,
Nature, Prevention, and Treatment of Tuberculous
and Scrofulous Diseases in general. By James
Clark, M. D., F. R. S. &c. In 1 vol. 8vo.

“. Clark’s Treatise on Consumption is the best that lias yet been publish-

ed in this country, or on the continent. It shows an intimate knowledge ol
the approv^ methods of diagnosis, and of he morbid anatomy so success-
fully investigated b’' 'he c ntinental pathologists, and by Professor Carswell;
while it displays an acquaintance with the recources of the system, and the
power of therapeutic agents, only possessed in this country and in Germany.’
Lancet, .August, 18^.

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

COLLABORATORS.

Elisha Bartlett, M. D. Professor of
Pathological Anatomy in the Berkshire
Medical Institution.

Jacob Bigelow, M. D. Professor of Ma-
teria Medica in Harvard University ,
Boston.

A. Brigham, M. D. of Hartford, Con-
necticut.

N, Chapman, M. D. Professor of the
Institutes and Practice of Physic and
Clinical Practice in the University of
Pennsylvania.

B. H. Coates, M. D. one of the Physi-
cians to the Pennsylvania Hospital.

Reynell Coates, M. D. of Philadel-
phia.

D. Francis Condie, M. D. of Philadel-
phia.

William P. Dewees, M. D. Late Pro-
fessor of Midwifery in the University
of Pennsylvania.

S. Henry Dickson, M. D. Professor of
the Institutes and Practice of Medicine
in the Medical College of the State of
South Carolina.

Gouverneur Emerson, M. D. of Phi-
ladelphia.

Charles Evans, M. D. Attending Phy-
sician to the Friends' Asylum, Frank-
ford.

John D. Fisher, M. D. of Boston.

E. Geddings, M. Professor of Patho-
logy and Medical Jurisprudence in the
M^ical College of the State of South
Carolina.

William Gibson, M. D. Professor of
Surgery in the University of Pennsy l-
vania.

R. E. Griffith, M. D. Professor of
Medicine in the University of Virgi-
nia.

Thomas Harris, Surgeon U. S. Navy,
and one of the Surgeons of the Penn-
sylvania Hospital.

E. Hale, M. D. Physician to the Mas-
sachusetts General Hospital.

George Hayward, M. D. Professor of
the Principles of Surgery and Clinical
Surgery in Harvard University, Bos-
ton.

C. A. Lee, M. D. of New York.

Samuel Jackson, M. D.Professorofthe

Institutes of Medicine in the University
of Pennsylvania.

Samuel Jackson, M. D. late of North-
umberland, Pennsylvania, now of Phi-
ladelphia.

William E. Horner, M. D. Professor
of Anatomy in the University of Penn-
sylvania.

Valentine Mott, M. D. Professor of
Pathological and Operative Surgery in
the College of Physicians and Surgeons,
New York.

James Mac Donald, M. D. late Resident
Physician to the Bloomingdale Asylum,
New York.

Reuben D. Mussey, M. D. Professor of
Surgery in the Medical College of Ohio.

T. D. Mutter, M. D. Lecturer on Sur-
gery.

G. W. Norris, M. D. one of the Sur-
geons to the Pennsylvania Hospital.

R. M. Patterson, M. D. Late Professor
of Natural Philosophy in the University
of Virginia.

C. W. Pennock, M. D. one of the Phy-
sicians to the Philadelphia Hospital,
Blockley.

R. R. Porter, M. D. Late Resident
Physician to the Friends' Asylum,
Frankford.

Thomas Sewall, M. D. Professor of
Anatomy and Physiology in the Co-
lumbian College, District of Columbia.

Ashbel Smith, M. D. Surgeon General
of the Texian Army.

Nathan R. Smith, Professor of the
Practice of Medicine in Transylvania
University.

Thomas Stewardson, M. D. one of the
Physicians to the Pennsylvania Hos-
pital.

A. F. Vache, M. D. of New York.

John Ware, M. D. Professor of the
Theory and Practice of Physic in
Harvard University , Boston.

John C. Warren, M. D. Professor of
Anatomy and Surgery in Harvard
University, Boston.

Edward Warren, M. D. of Boston.

John Watson, M. D. of New York.

Thomas H. Wright, M. D. Late Phy-
sician to the Baltimore Alms-house In-
firmary.

EDITOR — Isaac Hays, M. D., one of the Surgeons to Wills' Hospital for the
Blind and Lame, §rc.

TO READERS AND CORRESPONDENTS,

The following works have been received: —

Valedictory Address to the Students in Medicine of the College of Physicians
and surgeons of the University of New York. Delivered February 28th^ 18319.
By John B. Beck, M. D. Professor of Materia Medica and Medical Jurispru-
dence. New York, published by the students, 1839. (From the author.)

Catalogue of the officers and students of the University of Virginia. Session
of 1838-39. Richmond, 1839. (From Professor Griffith.)

A Catalogue of the Officers and Students in the Medical Department of the
Cincinnati College, for 1838-9. Containing the Catalogue of Graduates in
Medicine for 1839. Cincinnati: 1839.

The Art of Prolonging life briefly considered. A Lecture delivered before
the Athenian Institute, January, 1839. By J. Pancoast, M. D. (From the
author.)

Medical Lexicon. A new dictionar}?^ of Medical Science, containing a concise
account of the various subjects and terms; with a vocabulary of synonymes in
different languages, and formulae for various officinal preparations, &c., second
edition, with numerous modifications and additions. By Robley Dunglison,
M. D., M. A. P. S., &c. Philadelphia: 1839. Lea and Blanchard. (From the
publishers.)

Isagoge in Doctrinam Morborum Chronicorum. Auctore, G. C. B. Suringar,
M. D., &c., &c. Amstelodamae: 1837-8, 2 vols. (From Dr. Oppenheim )

Prospetto Statistico, Clinico, Psichiartrico, con classificazione dei recoverati
nel Regio Manecomio el Torino de Dottore, C. Bertolini. Torino: 1832.
(From Dr. Oppenheim.)

Saggio di Statistico del Regio Manicomio di Torino dal 1 di Gen,, 1831, al 31
dec. 1836. Del dottore G. S. Bonacossa. Torino: 1837. (From Dr, Oppen-
heim.)

Catalogue of the Officers and Students of the Medical Department of Hamp-
den Sidney College, in Richmond, Virginia. Session 1838-9. Richmond, 1839.
(From Professor Warner.)

Address delivered to the Graduates of the Philadelphia College of Pharmacy,
April 23d 1839. By Joseph Carson, M. D., Professor of Materia Medica and
Pharmacy. Philadelphia: 1839. (From the author.)

Minutes of the Medical Society of Tennessee, at the tenth annual meeting,
held in Nashville, May, 1839. Columbia: 1839.

Outlines of Physiology; with an Appendix on Phrenology. By P. M. Roget,
M. D., F. R. S. &c., &c. First American Edition, revised with numerous notes.
Philadelphia: Lea and Blanchard, 1839. (From the Publishers.) ~

The first Report of the Hospital at Mocao under the auspices of the Medical
Missionary Society of China. From the quarterly term beginning 5th July, and
ending 1st of October, 1838. By Rev. Peter Parker, M. D, Canton, China:
1838. (From Dr. William B. Diver.)

Twenty-second Annual Report on the state of the Asylum for the relief of
Persons deprived of their Reason. Published by direction of the Contributors.
Philadelphia: 1839. (From Dr. Charles Evans.)

Journal of the Proceedings of the Medical Convention of Ohio, at its third
session began and held in the city of Cleveland on the 14th and 15th days of
May, 1839. Cleveland: 1839. (From Dr. G. Mendenhall, Recording Sec-
retary.)

Proceedings of the President and Fellows of the Connecticut Medical Society
in Convention, May, 1839. With a list of the Members of the Society. Han-
ford: 1839. (From Dr. Welch, Secretary.)

TO READERS AND CORRESPONDENTS.

Diseases of the Uterus, a series of Clinical Lectures, delivered at the Hos-
pital la Pitie, by M. Lisfranc, and edited by H. Pauly, M. D. Translated from
the French by G. Henry Lodge, M. D., Fellow of the Massachusetts Medical
Society, &c., &c. Boston: W. D. Tickner, 1839. (From the Translator.)

The British and Foreign Medical Review’, April, 1839. (In exchange.)

The Edinburgh Medical and Surgical Journal, April, 1839. (In exchange.)

The Medico-Chirurgical Review, April, 1839. (In exchange.)

The London Medical Gazette, March, April, and May, 1839. (In exchange.)

Zeitschrif fur die Gesammte Medicin, herausgegeben Von. J. C. Fricke uiid
F. W. Oppenheim. December, 1838, and January, February, March, 1839.
' (In exchange.)

The Select Medical Library and Eclectic Journal of Medicine, May, June,
■’ and July, 1839. (In exchange.)

Boston Medical and Surgical Journal, May, June, and July, 1839. (In ex-
change.)

■ The Medical Examiner, May, June, and July, 1839. (In exchange.)

The American Medical Library and Intelligencer, May, June, and July, 1839.
(In exchange.)

The Southern Medical and Surgical Journal, May, and June, 1839. (In ex-
change.)

The American Journal of Dental Science, devoted to original articles, reviews
and dental publications, the latest improvement in Surgical and Mechanical
Dentistry, and Biographical Sketches of distinguished Dentists. New York,
Vol. i. No. 1. June 1839. (In exchange.)

The New York Journal of Medicine and Surgery. Published quarterly, July,
I 1839, V^ol. i. No. 1. (In exchange.)

CONTENTS

ORIGINAL COMMUNICATIONS.

MEMOIRS AND CASES.

ART. PAGE

I Report of Cases treated in the Wills Hospital for the Blind and Lame
during; the months of October, November and December, 1838, with
Observations. By Isaac Hays, M. D., one of the Surgeons to the
Institution. 265

II. Case of Vesico-vaginal Fistula, successfully treated by an operation.

By Geo. Hayward, M. D., one of the Surgeons to the Massachusetts
General Hospital. 283

III. A Case in which a portion of a Percussion Cap was extracted from

the Anterior Chamber of the Eye by an Operation. Communicated by
Thomas Sewall, M. D., of Washington, D. C. - - - 288

IV. Case of Sudden Death, with Remarks on that Occurrence. By

Edward Warren, M. D., of Boston, Massachusetts. - - -294

V. Remarks on Cholera Infantum. By Harvey Lindsley, M. D., of

Washington, D. C. - - - - - - - 301

VI. Report of Cases treated in the Baltimore Almshouse Hospital. By

Samuel Annan, M. D., Senior Physician to the Institution. - - 314

VII. Successful Operation for the purpose of Remedying a Deformity of
the Leg ; consequent to a badly set Fracture. By Charles Parry, M. D.

of Indianapolis, Ind. - 334

VIII. Notice of the Scarlet Fever as it occurred in the Valley of Virginia
and in the counties of Loudon and Fauquier in the year 1832; and of
the Treatment which proved the most successful. By H. D. Magill,

M. D., of Virginia. ------- 341

MONOGRAPH.

IX. On the Principal Diseases of the Liver. By N. Chapman, M. D.,
Professor of the Practice of Medicine in the University of Pennsylvania. 347

MEDICAL EDUCATION AND INSTITUTIONS.

X. The Gleanings in the East of a ci-devant Invalid, in 1838. By Valen-
tine Mott, M. D., of New York. - - - - - 367

ART.

CONTENTS.

PAGE

REVIEWS.

XI. Outlines of the Institutes of Medicine ; founded on the Philosophy
of the Human Economy, in Health and in Disease. In Three Parts.
Should we build facts upon facts until our pile reached the heavens, they
would tumble to pieces unless they were cemented by principles. — Rush,

By Joseph A. Gallup, M. D., 2 vols. Boston: Otis, Broaders, and Com-
pany, 1839. pp. 416 and 460, 8vo. ----- 375

XII. Outlines of the Principal Diseases of Females, chiefly for the use of
Students. By Fleetwood Churchill, M. D., Dublin, 1838, 8vo. pp. 402, 394

XII- De I’Albuminurie ou Hydropsie causee par maladie des Reins: modi-
flcations de I’urine dans cet etat morbide, a I’epogue critique des maladies
aig-ues et durant le cours de quelques affections bilieuses. Par le Dr.
Martin Solon, Medecin de I’Hopital Beaujon, Agrege a la Facultie de
Paris, Professeur particulier de Matiere Medicale et de Therapeutique,
Membre de I’Academie Royale de Medecine, Chevalier de la Legion
d’Honneur. Avec planches coloriees. Paris: 1838.

Of Albuminuria or Dropsy caused by Disease of the Kidneys ; of the altered
character of the urine in this disease, and also at the crisis of acute dis-
eases and during the course of certain bilious affections. By Dr. Martin
Solon, Physician of the Hospital Beaujon, &c. Paris, 1838. - - 404

BIBLIOGRAPHICAL NOTICES.

XIV. The Elements of Materia Medica; Comprehending the Natural His-
tory, Preparation, Properties, Composition, Effects, and Uses of Medi-
cines. Part I. Containing the General Action and Classification of
Medicines and the Mineral Materia Medica. By Jonathan Pereira, F.

R. S. and L. S. &c. London: 1839. - - - - 413

XV. Prospetto Statistico-Clinico-Psichiatrico con Classificazione dei Re-
coverati nel Regio Manicomio di Torino. Del Dottore Cipriano Bertolini,
Medico Primario del pio Institute. 8vo, pp. 205, Turin: 1832.

Saggio di Staiistica del Regio Manicomio di Torino, dal lodi gennaio 1831,
al 31 Decembre, 1836. Del Dottore Gio. Stefano Bonacossa, Medico
Assistente di detto Manicomio. 8vo. pp. 127, Turin: 1837. - - 414

XVI. On the Nature and Treatment of the Diseases of the Heart; with

some new Views on the Physiology of the Circulation. By James
Wardrop, M. D., &c. Part I. 8vo. pp. 100. London: 1837. - - 419

XVII. Isagoge in Doctrinam Moborum Chronicorum. Auctore Ger. Conv.
Bern. Suringar, Medicinae, Chirurgiae et artis obstetriae, Doctore, et Med-
icinae practicae in Schola Clinica et in illustri Amstelodamensium Athe-
naeo, Professore. 8vo. 2 vols. pp. 210 — 250. Amsterdam, 1837.

Introduction to the Study of Chronic Diseases. By G. C. B. Suringar,

M. D., Professor of the Practice of Medicine in the Clinical School and

Atheneum of Amsterdam. - - - - ' - - 422

XVIII. Annual Report of the Interments in the city and county of New
York for the Year 1838, with accompanying Remarks. By Henry G.
Dunnel, City Inspector. New York, 1839. - - - - 423

XIX. De Fungo Genu nec non de Tuberculis in hoc rnorbo inventis. Dis-
sertatio, quam pro Summis in Medicina et Chirurgiahonoribus rite capas-
sendis conscripsit acpublice defendit Franc. Josephus Lederle, Badensis.
Anno, MDCCCXXXVIII. 8vo. pp. 81. Petropoli: 1838.

An Inaugural Dissertation on Fungus of the Knee and on the Tubercules,
which occur in that disease. By F. J. Lederle, of Baden. - 425

XX. A Treatise on the Diseases produced hy Onanism, Masturbation, Self-
pollution, and other excesses. By L. Deslandes, M. D., &c. Transla-
ted from the French, with many additions. 12mo. pp. 252. Boston,

1838. - - - - - - - - 426

CONTENTS.

ART. PAGE

XXI. A Treatise on the Diseases of the Eye, and its Appendages. By
Richard Middlemore, M. R. C. S., Surgeon to the Birmingham Eye In-
firmary. London: 1835. 2 vols. 8vo. pp. 800 and 844.

Traitede I’Ophthalmie, la Cataracte et I’Amaurose, pour servirde supple-
ment au Traite des Maladies des Yeux de Weller. Par J. Sichel, M. D.
et C. &c. &c. Paris: 1837. pp. 750, 8vo. avec 4 planches coloriees.

Manual Pratiqne d’Opthalmologie, au Traite des Maladies des Yeux. Par
Victor Stoeber, M. D. &c. Bruxelles: 1837. pp. 389, 12mo. planches 3.

The Principles and Practice of Ophthalmic Surgery. Comprising the Anat-
omy, Physiology, and Pathology of the Eye, with the Treatment of its
diseases. By Benjamin Travers, Esq., F. R. S. &c., and Joseph Henry
Green, Esq., F. R. S. &c. &c. Edited by Alexander Cooper Lee. Lon-
don: 1839. pp. 242, 12mc.

Cours d’Ophthalmologie, au Traite completdes Maladies del’ceil, Professe
publiquement a I’Ecole pratique de Medecine de Paris. Par M. Rognetta,

E. Med. et C. &c. &c. Paris: 1839. pp. 468, 8vo.

Lectures on Diseases of the Eye. By John Morgan, F. L. S., Surgeon to
Guy’s Hospital, and Lecturer on Surgery, at that Institution. Illustrated
by 18 coloured plates. London: 1839. pp. 221. - - 427

XXII. Medical Lexicon. A New Dictionary of Medical Science, contain-
ing a concise Account of the various Subjects and Terms ; with a vocabu-
lary of Synonymes in Different Languages, and Formul2e for various
Officinal and Empirical Preparations, &c. 2d edition, with numerous
modifications and additions. By Robley Dunglison, M. D., M. A.,

P. S., &c. Philadelphia: Lea & Blanchard, 1839. pp. 821, 8vo. -429

XXIH. Transactions of the Medical Society of the State of New York,

Vol. iv. Part 2. Albany : 1839. pp. 56, 8vo.

Journal of the Proceedings of the Medical Convention of Ohio, at its Third
Session, begun and held in the City of Cleaveland, on the 14th and 15th
days of May, 1839. Cleaveland : 1839. pp. 48, 8vo.

Minutes of the Medical Society of Tennessee, at the Tenth Annual Meet-
ing, held in Nashville, May, 1839. Columbia: 1839. pp. 44, 8vo.

Proceedings of the President and Fellows of the Connecticut Medical
Society in Convention, May, 1839, with a List of the Members of the
Society. Hartford : 1839. pp. 16, 8vo. - 429

XXIY. On the Methods of Acquiring Knowledge. An Introductory Lec-
ture to the Course of the Institutes of Medicine, for the Session 1838-39.
Delivered in the University of Pennsylvania, Nov. 6, 1838. By Samuel
Jackson, M. D. Philadelphia: 1838. pp. 32. 8vo.

Valedictory Address to the Students in Medicine of the College of Physi-
cians and Surgeons of the University of New York. Delivered Feb. 28,
1839. By John B. Beck, M. D., Prof. Mat. Med. and Med. Juris. New
York : 1839. pp, 24, 8vo.

An address delivered to the Students of the Louisville Medical Institute,
in the presence of the citizens of the place, at the commencement of the
Second Session of the Institute, Nov. 13, 1838. By Joshua B. Flint,

M. D., Professor of Surgery. Louisville, Ken. ; 1838. pp. 31, 8yo.

An Annual Address to the Candidates for Degrees and Licenses in the
Medical Institution of Yale College, Feb. 26. 1839. By Thomas Miner,

M. D., Member of the Board of Examination, and late President of the
Connecticut Medical Society. Published at the request of the Class.
New Haven : 1839. pp. 20, 8vo.

An Address delivered to the Graduates of the Philadelphia College of
Pharmacy, April 23, 1839. By Joseph Carson, M. D. Prof. Mat. Med.
and Pharm. Philadelphia : 1839. pp. 16, 8vo. - - -431

XXV. Outlines of Physiology ; with an Appendix on Phrenology. By
P. M. Roget, M. D. &c. First American edition, revised, with nume-
rous notes. Philadelphia: 1839. pp. 516, 8vo. “ -432

CONTENTS.

SUMMARY I

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE

MEDICAL SCIENCES.

FOREIGN INTELLIGENCE.

General

PAGE

1. Case of Anaesthesia (Loss of
Sensation) in the course of dis-
tribution of the Fifth Nerve with
Remarks. By Dr. Romberg;. 433

2. Malformation of the Placenta.

By Dr. Durner. - - - 436

3. Transfusion of Blood. By Pro-
fessor BischofF. - - 437

4. On the Decussation of Fibres at
the junction of the Medulla Spi-

Pathological Anatomy

8. Perforation of the Stomach from
Morbid Causes. By Alfred. S.
Taylor. - 440

AND Physiology.

PAGE

nalis with the Medulla Oblon-
gata. By John Hilton. Esq. 437

5. An account of some Experi-
ments on the Blood, in connec-
tion with the theory of Respira-
tio. By John Davy, M. D. 438

6. Diurnal variations of the pulse.

By Professor Guy. - - 438

7. Products of Respiration at Dif-

ferent Periods of the Day. By
Charles T. Coathupe, Esq. - 439

.ND General Pathology.

9. Disorders of the Brain connect-
ed with Diseased Kidneys. By
Dr. William Addison. - 442

Materia Medica and General Therapeutics.

11. Formulae for Syrups of Co-
paiba. By M. Emile Mouchon. 445

12. On Remedial Powers of Cro-
ton Oil. By G. G. Sigmond,

M. D. - - - 1 445

Special Pathology and Special Therapeutics.

10. Employment of Sulphate of
Quinine in the form of ointment
for the cure of malignant inter-
mittents. By Dr. Antonini. 445

13. Puerperal Fever. By Profes-
sor Osiander. - - 447

14. Belladonna Plaster in Ner-
vous Palpitations, Irritable Blad-
der, &c. By Dr. Simpson. 450

15. External Application of Col-

chicum in Rheumatism. By
Dr. Thomas Laycock. - 450

15. Lytfa in Vesical Paralysis.

By Thomas Laycock. - 450

17. Case of Paralysis of the first
and second Branches of the
Sensitive Root of the fifth pair
of Nerves, with remarks. By
Dr. J. Corrigan, M. D.

18. Pathology and Treatment of

Phlegmasia Dolens. By John
Burne, M. D. - - - 455

19. Treatment of Quinsy by Scar-
fication. By M. Girardin. ' 459

CONTENTS.

PAGE

20. Use of Caustic Issues in

Phthisis Pulmonalis. By M.
Bricheteau. - - - 460

21. Inflammation of the Umbilical
Vein in Infants. By M. Duplay. 461

22. Case of Laryngitis, complica-
ted with Bronchocele, in which
the external application of Cro-
ton Oil was successfully em-
ployed. By A. Campbell, M. D. 462

23. Epidemic Scarlet Fever as it

occurred in Edinburgh. - 462

24. Account of Scarlet Fever as it
occurred in George Heriot’s

PAGE

Hospital, Edinburgh. By Wm.
Wood, F. R. S. E. - - 463

25. Extentof Prevalence and Mor-
tality of the Epidemic Scarlet
Fever in some of the Public In-
stitutions of Edinburgh. By
Wm. Wood, F. R. S. E. - 474

26. On the Treatment of Scarla-

tina Anginosa. Ry Dr. Hamil-
ton. . _ _ _ 475

27. On the Scarlet Fever Epidemic

in Edinburgh in 1835-36. By
Charles Sidey, Esq. - - 478

Surgery.

28. Fracture of the Acetabulum.

By Dr. Charles Lendrick. 481

29. On the Pathology of Burns

and Scalds. By Samuel Coop-
er, Esq. . . - . 481

30. Complete Anchylosis of the
five superior cervical vertebrae to
each other, and complete dis-
location backwards of the fifth
from the sixth, without fracture.

By Mr. S. S. Stanley. - . 484

31. On the varieties and Treat-
ment of Fractures of the Ribs.

By J. F. Malgaigne. - - 485

32. On the application of Raw
Cotton to Erysipelatous Sur-
faces. By M. Reynaud. - 490

33. Deafness from Disease of the

Lining Membrane of the Tym-
panum.— Use of the Acetate of
Lead. By Mr. Arnott. - 491

34. Congenital Club-Foot. By

Dr. Krauss. - - - 491

35. Case of Ranula in which the
left submaxillary gland was ex-
tirpated. By J. G. Malcomson,

Esq. . . - - - 493

36. Suetin’s Immovable Fracture-
apparatus. By Dr. Fricke. 495

37. Case of Extensive Aneurism
by Anastomosis, in a child ten
months old, involving the bran-
ches of the Temporal and poste-
rior Auricular Arteries, treated
successfully by the Twisted Su-
ture. By Dr. J. Maclachlan. 495

Ophthalmology.

38. On Injuries of the Eye by 39. Iris Sympathetica. By Mr.
Percussion Caps. By Samuel Mackenzie. - 500

Crompton, Esq. - - 498

Medical Jurisprudence and Toxicology.

40. Child at Birth of Enormous
Size. By Mr. J. D. Owens. 504

41. On the manner in which death

is produced by Carbonic Acid
Gas. By Dr. Golding Bird. 505

Midwifery.

42. Cartilaginous Condition of the
Neck of the Uterus — Incision of
this part to facilitate delivery.

By Dr. Burdach. - - - 507

43. Prolapsus of the Uterus — In-
cision into the Neck of the Or-
gan— Cure. By Dr. Gruhn. - 507

xii

CONTENTS.

Medical Statistics.

PAGE

44. Statistics of Patients Affected

with Calculus, admitted into the
Hospital of St. Mary at Mos-
cow. By Dr. De Roos. - - 508

45. Prussian Bills of Mortality. —
Results gleaned from the Regis-

PAGE

ter of Births, Marriages, and
Bills of Mortality in the Prus-
sian dominions, during the year
1836. Officially reported by the
Government. - 509

AMERICAN INTELLIGENCE.

On the Value of the Catroptic ex-
amination of the Eye as a means
of Diagnosis. By I. Hays, M.D. 513
Note on Flxtraction of Foreign
Bodies from the Eye. By I.
Hays, M. D. - - - - 514

Cases of Negro Poisoning. By A.

Somervail, M. D. - - - 514

Case of Exostosis of Upper Jaw,
successfully treated by B. A.
Rodrigues, M. D. - - - 516

Notice of the Cape May Albinos.

By Dr. Samuel L. Marcy. - 517
Abstraction of the Uterus after De-
livery. By John H. Griscom,

M. D. 518

Successful Treatment of Erysipe-
las by Raw Cotton. By. Dr. F.

M. Robertson. - - - 521

Case illustrative of the Etiology of
Spontaneous Amputation of the
Limbs of the Foetus in Utero.

By A. H. Buchanan, M. D. - 522
Fresh Vacicine Virus. By Dr. C.

A. Lee. ----- 522

Dr. Bartlett’s Case of Double Con-
sciousness. - 522

Albany Medical College and the
Thomsonians. . - - 523

Remarks on Enlargement of the
Tonsils, attended by certain De-
formities of the Chest. By J.
Mason Warren, M. D. - - 523

Convention for the Revision of the
Pharmacopoeia. - 527

Cincinnati College. - - - 527

University of Virginia. - - 527

Medical Department of Hampden
Sidney College, in Richmond,

Va. - - - - - 528

Albany Medical College. - - 528

American Journal of Dental Sci-
ence, Devoted to Original Arti-
cles, Reviews of Dental Publica-
tions, the Latest Improvements
in Surgical and Mechanical Den-

tistry, and Biographical Sketch-
es of Distinguished Dentists. - 528
The New York Journal of Medi-
cine and Surgery. - - - 528

Memorial to Congress for the
Enactment of a Law for the
Transmission of Vaccine Virus
by Mail Free of Postage. - 528

Forthcoming Work. - - - 528

ERRATA.

Page 268, line 15 from top, for “ subject,” read subjected,^"*

^ “ 281, last line, for “ 1833,” read “ 1823.”

“ 282, line 22 from top, for “is not to be,” read '‘^cannot beJ*^

“ 287, “16 “ for “ renewed,” read “rmoucfl?.”

“ 287, “ 22 “ for “ set,” read “ sa^.”

THE

AMERICAN JOURNAL

OF THE

MEDICAL SCIENCES.

Article I. Report of Cases treated in the Wills Hospital for the Blind and
Lame during the months of October, November and December, 1838, with
Observations. By Isaac Hays, M. D., one of the Surgeons to the Insti-
tution.

OpHTHHALMic surgery, it must be conceded, has not been sufficiently
cultivated in this country. There are, unquestionably, a limited number of
practitioners among us who are well versed in the subject; but the great mass
of the profession are entirely unacquainted with its comprehensiveness — the
variety of affections it embraces, and consequently they can have but a faint
conception of its importance; it is to them, in short, a complete terra incog-
nita. We have been told by a professor of surgery in a school of high
standing, that he found three lectures ample for teaching every thing of con-
sequence relative to the diseases of the eyes, and in none of our schools, so
far as we can learn, are these affections considered of sufficient moment to
require half a dozen lectures to be devoted to them. There is not, moreover,
with one solitary exception, we believe, a private course delivered in this
country, on the subject of these diseases.

Very different is the estimation in which Ophthalmic surgery is held in
Europe. In the principal German and Italian universities, in the university
of Glasgow and in the Birmingham Royal School of Medicine and Surgery,
the teaching of this branch is made the province of a distinct professorship;
and numerous independent courses are delivered at the various hospitals, in-
firmaries and dispensaries established for the relief of those afflicted with
diseases of the eyes.

As to the extent of the subject, some idea may be formed from the fact,
No. XLVIII,^ — August, 1839. 23

266 Hays’s Report of Cases Treated in Wills Hospital,

that Professor Beer, of Vienna, occupied in his course of instruction ten
months, giving five or six lectures weekly, and this on the practical part of
the subject alone, Prochaska being professor of general Ophthalmology in
the same school.

With the hope of drawing attention to this neglected department of our
science we propose to report some of the more interesting cases which offer
in the Wills Hospital. This hospital is restricted to the reception of patients
affected with diseases of the eyes or lameness, but the former class compose
by far the greater number.*

It is unquestionably in such institutions that these diseases can be studied
with most advantage, and we hope in these reports, especially should our
colleagues unite in the plan, that most of the forms of disease to which the
eye is subject will eventually be illustrated. These are of course numerous,
since this organ embraces in its structure nearly all the tissues found in the
other parts of the frame, and at least two which exist no where else.

During the last quarter of the year 1838, the cases treated in the hospital
were of a less varied character than usual, but some of them were exceed-
ingly interesting. These last we will now briefly notice, without giving a
diary of each case which might be considered tedious.

Amaurosis. — This form of blindness may result from any organic disease
'of the retina, optic nerve, anterior tuberculi quadrigemini, the corpus genicu-
labum externum or tuber cenerium; from tumours in their neighbourhood
.pressing upon them and thus preventing the performance of their functions;
from various disorders of other organs causing congestion in these parts or
■affecting them sympathetically, as the suppression of habitual discharges,
worms dn the intestines, derangement of the stomach, <fec., &c; and finally
ifrom oertain lesions of some of the branches of the fifth, third, and sixth pairs
^df nerves, of thcigreat sympathetic and probably also of the spinal marrow.
It is manifest then that the forms of this disease are exceedingly numerous
and the importance of ascertaining the particular one in every case will be
rreadi'ly^osiimaled, since some of them are entirely incurable, and it is cruel
;to sulyect patients so afflicted to severe remedies, which must prove un-
availing. Whilst those which are remediable, are of so different a cha-
racter as to require various and even opposite modes of treatment, and the
appropriate one can solely be determined by a knowledge of the pathological
state upon which the disease depends. Unfortunately in the present state of
the science this is not always possible, but very generally, a careful ex-
amination into the history of the ease and of the existing symptoms will
furnish us with the desired information.

One of the most interesting cases of amaurosis treated in the Hospital was
the following, the result apparently of nervous asthenia of the retina.

* For an interesting account of this hospital by Dr. Littell see this Journal for November
1835, Vol. XVII, p. 89.

267

Hays’s Report of Caffes Treated in Wills Hospital,

Case. Amaurosis — Employment of Strychnine — Cure. Harriet Taylor,
aged 12, was admitted November 10th, wdth amaurosis of right eye; vision
in left eye good. Her mother stated that she had first noticed her daughter’s
defect of sight about three years ago, since which period it had been growing
gradually worse. For four months the right eye, to use the patient’s own
expression, had been “ quite dark.” She cannot distinguish a candle' with
it, though she has a faint perception of the light. The patient has light hair;
complexion fair; irides gray, contracting on exposure to light; pupil of right
eye rather more dilated than that of left; is sometimes troubled with head-
ache. We neglected to examine the eye catoptrically.

Ordered a dose of sulphate of magnesia at bed time, and the next morning
a few drops of the following to be applied to her right eye. R, strychnin,
gr. ij; acid. acet. ^j. aq. puree^gj. M.

November \\ th. ^oow. Medicine has purged her actively. The nurse
had applied the solution to the eye early in the morning, and the patient
finding her vision much improved, afterwards, in the absence of the nurse
had twice used it herself. Says she can now see pretty well with her right
eye. Upon trial found she could read with that eye, the other being care-
fully closed with my fingers, a newspaper which happened to be at hand.
Says there is some cloudiness of right eye. Continue collyrium.

12//i. Sight improved. She read with either eye almost equally well,
the other being closed, a proof sheet of this Journal, which we had taken for
the purpose of trial. Cloud before right eye diminished but not entirely
gone. Continue collyrium.

\Wi. Cloudiness of right eye entirely gone; sees perfectly well with it;
is not sensible of any difference in the power of vision of her t\yo eyes. She
was discharged November 17th, and went to her mother who resides a few
miles in the country.

Remarks. The rapidity of the cure in this case led us at first to suspect
deception; on inquiry we could not discover any ground for such suspicion.
The friend who had recommended the patient to our care informed us that
her mother was a respectable, industrious widow, who supported by her
labour several children of which the patient was the oldest; that the daugh-
ter was intelligent, active and obliging and her aid was of so much impor-
tance to her mother, that he had interested himself to have her relieved from
her infirmity, which much lessened her usefulness. As to the excellence of
her sight, when she was discharged the hospital, we verified this in a way that
admitted of no deception.

P. S. We have this day, (June 11th, 1839,) had the gratification to
learn from the friend who sent this patient to us, that the cure has been
permanent. He informs us, that he sees Harriet frequently and that ten
days since he inquired particularly of her respecting her sight, and was
assured by her that it was perfect.

A very interesting case of congestive amaurosis was treated in the hospital,

268 Hays’s Report of Cases Treated m Wills Hospital,

but as the result is not yet determined, we will merely state at present in
relation to it, that it occurred in a gentleman fifty-eight years of age, and
resulted from the suppression of an habitual hemorrhoidal discharge. The
patient was improving under the use of active cathartics and the repeated
application of leeches to the anus; when he was attacked with rheumatism,
to which he was subject, of so severe a character as to require a treatment
exclusively directed to its removal. His health was so much impaired by
this complaint that it was thought advisable he should return home to the
country to recruit.

Case, Amaurosis — Various treatment — Vision not improved. — Louisa
Dewey, aetat. 24; seamstress. This patient had been admitted into the
house on the 29th of August, She attributed her affection to sewing late
at night, and at times all night, by gas-light, during the preceding winter
and spring. She had been repeatedly blistered, and had strychnine applied
to the raw surface thereby produced, and been subject to other treatment
without benefit.

When she came under our care, October 1st, her health was excellent;
her only complaint was of imperfect vision. She was a brunette, with dark
hair; irides brown, inactive; pupils dilated, clear black; three distinct images
of a flame to be seen in them; sclerotica free from injected vessels. It was
difficult to determine what was the exact degree of vision enjoyed by this
patient; she seemed to me disposed to exaggerate her blindness, and rarely
admitted that any improvement resulted from the remedies employed,
even when those about her thought that she exhibited marked evidences of
improved vision. We can hardly suspect her, however, of intentional decep-
tion, as she submitted cheerfully to the severest remedies, and repeatedly
requested that she might be discharged, so soon as we gave up all hope of
benefitting her sight. We had no reason, however, to believe that the im-
provement, if any, was permanent.

The means employed in this case, were various. Our first impression was,
that the loss of sight was the result of an asthenic condition of the retina; but
the failure of the appropriate remedies, under the direction of our predecessor,
led to the suspicion that there might exist some congestion; topical depletion
was therefore employed — as cups to the head, and leeches to the temples. With
the same view, numerous derivatives were ordered: among which may be
mentioned a seton in the back of the neck, mustard pedeluvia, purgatives,
Slc, The few occasions on which she admitted herself to be benefitted by
any remedy, was after the first application of leeches to the temples; their
subsequent employment however was of no service.

Failing in these remedies, we determined to treat it as a case of asthenia of
the retina. With this view cauterization of the cornea, with nit. argent., as
recommended by Sanson, was tried; then solution of strychnine dropped in the
eye, and finally an alterative treatment, all with the same result. When we

269

Hays’s Report of Cases Treated in Wills Hospital,

turned her over to the care of our successor, her sight had not improved,
and we find by the register, that she was discharged January 30th, 1839, as
incurable.

Remarks. The want of success in the treatment of this case is not rea-
dily to be explained. The good health of the patient, and the recent occur-
rence of the disease would seem to have promised a more favourable result.
Our first impressions relative to the nature of the case, viz, that it was one
of asthenia of the retina, were probably correct: nevertheless an energetic
treatment directed by this view was wholly unavailing.

When we took charge of the hospital on the 1st of May, 1839, we found
in it a case remarkably similar to the preceding in its main features, but
which terminated more favourably. The patient Susan Smith, was a seam-
stress, aetat. 22, fair complexion, light hair and light blue irides. She had
been admitted April 3d, by our colleague Dr. Fox. She was treated by
purgatives, shower bath and moxas to the temples, and was discharged cured
May 29th.* She then read for us promptly, several verses in a diamond
print Bible.

The following case, though it occurred in private practice, it may be
allowable to introduce here, as it furnishes a marked example of congestive
amaurosis and of the benefits of a proper statement.

Case, Congestive Amaurosis — Depletion — Cure. Margaret M’Quid
aetat. 19, a robust Irish girl, a servant in a family in West Philadelphia, applied
to me February 18th, 1839. She stated that she had lost the sight of her
left eye suddenly, tv/o days previously whilst washing clothes ; she had at
that lime intense headache which still continues. Her bowels are openj
menstruates regularly; eyes natural in appearance — three images of
a flame visible in the pupil. Irides light blue, moderately active; pupil
mean size. Vision with right eye perfect, with left she cannot distinguish
any object, not even a lighted candle, though she has a faint perception of the
light it emits. She is of full habit; pulse active. I ordered her to he bled
to the extent of sixteen or eighteen ounces and to take the following pills.

R. calomel pp. gr. viij; pulv. rhei gr. x; G. aloes gr. ij. M. Ft. pilul.
No. iv.

20/A. The patient had neglected to attend to these prescriptions until
last evening. The headache had been promptly relieved by the bleeding.
Pills have not operated; there is a slight improvement in vision. Ordered '
magnes. sulph. ^j.

22rf. Medicine has operated freely. Can see now pretty well the
smallest objects, though they all appear as through a thin mist. Ordered
a blister behind right ear, and senna and manna tea.

27/A. Vision quite restored. Intends returning to her place.

* We abstain from giving the details of this case, which we hope will be furnished here-
after by Dr. Fox, under whose care the patient was admitted,

23*

270

Hays’s Report of Cases Treated in Wills Hospital,

I met this patient in the street ten or twelve days subsequently, and
learned from her that her sight was as perfect as ever.

Cataract. Of this disease, we shall relate but two cases; one of capsulo-
lenticular, the other of capsular (congenital) cataract.

Case. Capsulo-lenticular Cataract — Adhesion of Iris to Capsule at
several points. — Susan Clay. This woman, when I took charge of the
house, was recovering from an operation for cataract, which had been per-
formed on both eyes, by my predecessor. She was 63 years of age, short,
very fat, flesh soft and flabby. She complained much of weakness; pulse
feeble; had no appetite, and labored under the usual symptoms of derange-
ment of the digestive organs. She was ordered the following pills. R*
pulv. rhei 5j; pulv. zingib.. 3ss; sapo. venet. Bj; M. Ft. pilul. No. xxiv.
Two to be taken half an hour before each meal. Her diet was regulated; a
small portion of meat was occasionally allowed at dinner, and subsequently
she took cold chamomile tea. Under this treatment, her digestive organs
were restored to a more healthy condition, and she gained strength; but no
improvement took place in her sight She was able merely to distinguish
light; and it was agreed in consultation, to repeat the operation.

A mild purgative being premised, and the extract of belladonna applied
around the eyes the night before, I operated October 18th, assisted by my
colleagues. The pupils admitted of only moderate dilatation, in consequence
of adhesions between the margin of the iris, and capsule of the lens.

The patient being laid on a table, her head raised on a couple of pillows,
(the position in which we always operate for cataract,) a straight, pointed,
double-edged needle was introduced about a line and a half behind the
cornea, with one flat surface towards the lens, and pushed forward between
the lens and iris, until its point appeared in the pupil. The adhesions were
carefully separated with the edge and point of the instrument, which was
effected without wounding the iris; the needle was next carried entirely
across the pupil, and one cutting edge being then turned towards the lens,
it was partially withdrawn, dividing the lens exactly in half. The two
fragments were then broken up, and some of them pushed into the anterior
chamber. The patient was put to bed in a dark room, the strictest absti-
nence enjoined; barley water for sole nourishment; and belladonna to
be applied every night around the eye. Slight inflammation followed the
operation, but this yielded to a small bleeding, and a few applications of
cups to the head, and back of the neck.

She was soon able to take mild nourishment, which was allowed as early
as circumstances would permit, on account of her previous feebleness and the
derangement of her digestive organs. Absorption went on rapidly, and on
the 27th November, she was discharged, being desirous to return to her
family, who resided some miles in the country. At this time, she was able
to read with one eye, and to distinguish persons with the other. There is
little doubt but that the whole cataract w^as eventually absorbed.

271

Hays’s Report of Cases Treated hi Wills HospilaL

Case. Capsular Caroline B— — , getat. 23, was admitted

October 3d, with cataract in the left eye. She stated that she had not
enjoyed, since her earliest recollection, sight with that eye, and within a
short period, she found her other eye was becoming weak from excessive
use, in teaching school during the day and sewing at night, and she was
afraid of losing the sight of this one also. There was no sign of cataract
in this eye; three images of a flame were seen in it; there existed merely
an irritability of the retina, from excessive employment of the organ. Her
situation, which was a peculiar one, rendered her unwilling to give up her
occupations and become the inmate of an hospital for the relief of her right
eye; but she was satisfied to do so for the purpose of an operation on her
left one. Though reluctant to operate upon one eye, whilst vision is
pretty good in the other, I consented to waive this on the present occasion,
as the treatment to which she would then be subject, appeared to afford the
only prospect of curing her right eye, or probably, indeed, preventing her
losing the sight of it entirely.

The cataract in the left eye was pure white, very dense, with a minute
dark spot near the centre, apparently a small opening. There was no adhe-
sion of iris to capsule, the pupil freely dilating under the action of bella-
donna. The patient could distinguish with her left eye, the position of a
light, and tell when an opaque body was interposed.

The history of the case, as well as the appearance of the opacity, led me
to believe that the cataract was membranous, probably formed by the union
of the anterior and posterior surface of the capsule, the lens having been
absorbed, and that it would require some management to cut it up with a
needle.

The patient was put upon a light diet, her bowels regulated.

October 18//i. We this day operated in the presence of our colleagues.
The pupil was well dilated by the extract of belladonna, which had been
applied around the eye last night, and again early this morning, A straight,
pointed, double-edged cutting needle was introduced through the sclerotica,
at the usual place, with one flat surface towards the iris, and passed across
the pupil, until its edge became concealed behind the nasal margin of the
iris. The edge was next turned, so as to correspond as nearly as possible
to the diameter of the cataract, against which it was firmly pressed; then with
,a short, quick stroke, the cataract was divided entirely, and exactly in half.
The lower half was next cut up, and the fragments placed in the anterior
chamber, and then the upper half divided several times, but it could not be
cut up as well as the other half. Belladonna was ordered to be applied
around her eye at bed lime.

The night after the operation, this patient became maniacal, and upon
inquiry, we learned that she had had several such attacks before, and had, at one
lime, been for several months confined in a lunatic asylum. The present
attack yielded to venesection, cups to the head, and tart, antim. in small doses

272

Hays’s Report of Cases Treated in Wills Hospital,

combined with laudanum, as did several others subsequently; and these
means also relieved some slight inflammation of the eye which followed the
operation.

Absorption went on very rapidly, and all the fragments in the anterior
chamber were removed by the 6th of November; and her mind was then
perfectly clear.

At this period, a sudden attack of mania came on at midnight; she left
her bed, got into the bath tub, turned the valve which let the water flow to
the shower bath, and the steward, who was awakened by the noise of the
flowing water, found her complety drenched. The consequence of such an
exploit, on a cold November night, as might be supposed, was a severe
inflammation of her eye. This yielded, however, to an active antiphlogistic
treatment. It is worthy of mention that there was a large fragment of cap-
sule, the morning after this event, in the anterior chamber, which had passed
into it from the posterior, doubtless in consequence of some sudden jar.

Notwithstanding these untoward occurrences, absorption went on well, and
on the 20th of December, no portion of the cataract remained except a small
fragment behind the upper and outer edge of the iris. The pupil when
viewed in front was entirely clear, no injection of the conjunctiva. The
patient can count the number of fingers held up, and distinguish different
persons with her left eye.

The right eye has improved; indeed her sight with it seems now perfect.
Being troublespme from her repeated attacks of mania, she was discharged
December 26th.

She has since, we learn, had a severe attack of mania and is now in the
Insane department of the Pennsylvania Hospital.

Iritis. No acute case of this disease presented at the hospital. The
following example of the sequelae of the complaint is interesting from the
complete cure effected.

Case, Lymph in Pupil the sequela of Iritis, — David Jackson, aetat. 24,
had been admitted into the house, August 29th 1 838, for iritis, by my predeces-
sor Dr. Littell. Under the judicious treatment to which he had been subjected
his sight had much improved, and when he came under my care his vision
with one eye was tolerably good, with the other it was very imperfect.
The pupils were small, irregular and considerable lymph still in them. No
inflammation. The attack had come on in May last, first in one eye and a
few days subsequently in the other.

October 2d, Extract, belladonnae cum ung. hydrarg. part, aggales. was
directed to be applied around his eye every night.

19//i. Ordered the following. R. calomel pp. gr x.; tart, antim. gr. j; nit.
potass. 3j; M. Div. in chart. No. xii. Four to be given daily; Continue
local application.

On the 29th of October, his mouth became sore, when the powders were

273

Hays’s Report of Cases Treated in Wills Hospital.

discontinued and he was ordered the compound syrup of sarsaparilla. Under
this treatment the pupils dilated, the lymph was absorbed and vision im-
proved so much that he was able to pass a portion of each day in reading
the newspapers to a Mr. V — , a patient in the house. When my term of
service expired he could read, with one eye, the smallest lettering on a map
of the United States in the office, and with the other eye, could read very
small print. He was discharged, cured, February 20th, 1839.

Purulent Conjunctivitis. But a single acute case of this disease was
admitted into the Hospital during our tour of duty.

Case. Catarrhal Conjunctivitis--^Chemosis — Ulceration of Cornea. —
John Moffit, aetat, 30, a short robust Irishman, a labourer on the Schuylkill
coal wharves, admitted October 13th, with purulent conjunctivitis of right
eye. He had been attacked some days previous to admission, in consequence
of taking cold. His right eye was extremely inflamed; chemosed and dis-
charged pus copiously. The conjunctiva was so distended that it projected
over the margin of the cornea covering nearly half the circumference of this
coat; pulse active; considerable pain in his head. Left eye not inflamed but
light slightly oflensive to it.

This patient was several times bled and cupped, his bowels were kept open
and his eye was washed with a collyrium of corrosive sublimate, gr. ij. in four
ounces of water. The ehemosis not yielding to this treatment, the conjunc-
tiva was divided in a radiated manner according to the plan recommended by
Mr. Tyrrell, (see this Journal for November 1838, p. 242.) The swel-
ling of the conjunctiva abated and a deep ulcer was then observed near the
margin of the cornea on that part previously covered by the swollen conjunc-
tiva. This ulcer was lightly touched several times with solid nitrate of silver.
Dover’s powders and mustard pediluvia were ordered at bed time and finally
a blister behind the neck. Under this treatment the inflammation was sub-
dued and the ulcer healed. There was however a small point of adhesion
between the iris and cornea causing a slight irregularity of the pupil. The
patient w'as discharged with his sight entirely restored, December 22d.

Remarks. In the preceding case, depletion was more frequently em-
ployed, than is usually necessary. It seemed to us to be demanded by the
severe and constant pain in the head. The division of the conjunctiva by
the method recommended by Mr. Tyrrel, did not seem to be productive of
the benefit we expected from the representations of that surgeon; but it
would be unfair to condemn it from the result of a single trial.

In most cases of catarrhal conjunctivitis, sanguineous depletion can be
dispensed with; and a cure be effected more promptly by the local applica-
tion of nitrate of silver. Our prejudices were originally strongly against
this method of treatment; but ample experience has demonstrated to us its
superiority — a cure being produced in infinitely less time, and with less suf-
fering to the patient.

274 Hays’s Report of Cases Treated \n Tfills Hospital.

The following cases which occurred in private practice, we may adduce
as illustrative of this.

Mrs. M , aged about forty-five years, thin, health pretty good, though

formerly a great sufferer from dyspepsia, consulted me, April 19th, 1839.

She had inflammation of conjunctiva, which had come on two days pre-
viously, in consequence, she thinks, of exposure to cold. The conjunctiva
of both eyes is injected; considerable effusion of serous fluid beneath it, consti-
tuting chemosis, but of a paler character than usual. Scarcely any intole-
rance of light; slight feeling of sand in the eyes; some lachrymation; pulse
natural; no headache. She had taken, the night before, a purgative, which
had operated well.

I ordered nit. argent, gr. iss; aq. purae ^j. M. Of this, I placed a few
drops on the eye, this and the six succeeding mornings. She was directed to
wash her eyes occasionally during the day, with the following collyrium. — R.
corros. sub. gr. j; aq. purae giv. M. Mild diet was directed, and avoidance
of exposure; room to be moderately lighted; mustard pedulivium every night;
one or two mild laxatives were given. Under this simple treatment, in six
days the redness and chemosis entirely disappeared, and the patient ex-
pressed her surprise at the rapidity of the relief.

Mr. H. E applied to me, Saturday, June 1st, with inflammation of

right eye. There was considerable serous chemosis, and also swelling of the
lids; no intolerance of light; pulse natural; no constitutional derangement
Patient attributes his attack to taking cold the preceding Wednesday night,
when he had been obliged to rise from bed and go a considerable distance.
He had taken, the night previously to our seeing him, a dose of salts,
which had operated. We applied a few drops of a solution of nit. argent,
to his eye, of the strength of one grain and a half to the ounce of water.
It produced slight smarting, which soon went off. This was repeated June
2d and 3d. June 4th, the patient called again, and said he had done so in
compliance with our request, but that his eye was well, and no further
application was necessary.

Remarks. The want of success sometimes attendant upon the use of the
solution of nitrate of silver, is to be in a great degree attributed, we believe, to
the careless manner in which this preparation is made. Both the nitrate of
silver and the water should be chemically pure, and the solution perfectly
pellucid. It must be observed, moreover, that it is best when freshly pre-
pared. In a few days, or if exposed to the light, in a few hours, the solu-
lution assumes a reddish tint, and small dark particles may be perceived
floating in it. In this state, its use is often followed by injury, instead of
benefit.

Chronic Purulent CoNJUNCTivms with Granular Lids. — A greater
number of patients are admitted into the hospital for this, than for any other
'diseases of the eyes. This arises, doubtless, from the fact of the disease

275

Hays’s Report of Cases Treated in Wills Hospital,

being generally but little understood by physicians ; consequently, pa-
tients, finding no benefit from the usual treatment, wander from place to
place in hopes of obtaining relief. As an evidence of how little the complaint
is understood, it may be stated, that a gentleman of wealth, from Missis-
sippi, who had long been suffering from it, and had consulted many eminent
physicians without relief, asssured us, that although one or two of those who
had given him advice had suggested that the obstinacy of his disease might be
owing to granulations; that the only means by which the existence of these
granulations could be detected (the eversion of the lids) had never been
resorted to until by ourself, and that no direct application had ever been
made to them. This gentleman, who came here quite blind, recovered his
sight after the removal of the granulations.

Most of the cases in the house had been there for a considerable period,
and as they do not illustrate the principal points to which we are desirous of
calling attention, we must postpone the remarks we wish to make, for a
better opportunity.

The following case will show the ordinary features of the complaint and
general mode of treatment; and is interesting from the great improvement
which took place. Like many of the cases of this complaint, it was pro-
tracted in its course, and the result should serve to stimulate the practitioner
to perseverance under the most discouraging circumstances.

Case. Chronic Purulent Conjunctivitis — Opacity of the Cornea —
Granular Lids. — Terence Hagan, aetat. 30, admitted September 30th, 1837.
— This man stated that he had been attacked in November, 1836, with
inflammation of both eyes, accompanied with discharge of matter; that after
having been some time treated by a physician in New Jersey, finding his
disease not abating, he went, the following March, to the city of New York,
where he was treated by scarifying the lower lids, repeated cupping from
the head, and took pills which made his mouth sore. Being dissatisfied
with the result of this treatment, he came on to Philadelphia.

When he applied at the hospital, the propriety of granting him a certificate
that he was not incurable, W'hich is necessary for admission, seemed to me
doubtful. At this time, his cornea was so completely opake with effused
lymph, that he could barely distinguish day from night; his ocular conjunc-
tiva was a mass of red vessels, through which the natural colour of the scle-
rotica could not be seen; the palpebral conjunctiva of the upper lids were
covered with large, firm, wart-like looking granulations; and that of the
lower lids showed numerous cicatrices, the consequences of deep scarifica-
tions. There was some intolerance to light, with cephalalgia, and sense of
weight in the head; pulse moderately active.

The day he was admitted, cups were applied to his head, and ten or
twelve ounces of blood taken, and an active purgative was prescribed.
These remedies relieved his headache, and abated the intolerance of light.
He w^s then subjected to the following treatment, which was persevered in

276

Hays’s Report of Cases Treated in Wills Hospital,

with little variation during the three months he continued under our care.
Cups were applied to his head every few days, the period determined by
the recurrence of the headache, which was frequent, and by the increase
in the injection of the conjunctival vessels; purgatives were given as re-
vulsives, and to correct the torpid state of the bowels; a mild, light diet
principally vegetable, was directed; and the solid sulphate of copper applied
every two or three days, to conjunctiva of upper lids, and occasionally to
that of the lower. This local application was made with difficulty in this
case, inasmuch as it was impossible to completely evert the upper eye lids.
The only way it could be effected, was by drawing the lid from the ball,
inserting a thin piece of the article, fixed in a quill, between the lid and
ball, and then rubbing it against the former. Under this treatment, the
granulations diminished, as also the injection of the ocular conjunctiva, and
absorption of the lymph in the cornea commenced.

The treatment was continued by my colleagues, modified occasionally to
suit varying circumstances or in conformity to peculiar views. The only
change however we need notice is the administration of iodine, which was
given partly to promote absorption and partly to relieve scrofulous swellings
of the glands of his neck, which occurred and proved troublesome; suppurat-
ing and causing much discomfort to the patient.

On the 1st of October, 1838, Hagan again came under our care. His eyes
during the interval had much improved. Distinct vessels could now be seen
on the ocular conjunctiva, between which the natural colour of the sclerotica
was visible. The granulations had nearly disappeared, and a large portion of
the lymph on the cornea had been removed.

The upper lids could now be everted and the sulphate of copper was
occasionally applied to them. Hagan still suffered at times from headache
from which he was always relieved by cups to the head, and this remedy
also served to diminish the injection of the conjunctival vessels. The shower
bath was also directed as long as the weather permitted, and as his bowels
were still inactive, the pil. cathart. comp, two or three at bed time. The
glands of his neck, particularly of right side, were swollen, indurated and
occasionally discharged pus. To correct this condition, which we suspected
might have some dependence on a syphilitic taint, we ordered on the 10th
of October, the syrup of sarsaparilla §j. three times a day wdth one tenth of a
grain of corrosive sublimate. The latter was given as follows: R. corros.
sub. g. j; spt. vin. 3j. solv. et add. aq. purae ^v. M. liq. A tablespoonful
with the syr. sars. three times a day.

This was continued for a month, at the end of which the swelling of the
glands had diminished and also the injection of the eyes. A seton was then
inserted in his neck, and a few drops of vin.^opii placed daily on his eye,
and mustard pedeluvia were ordered twice a week at bed time. Cups were
still occasionally required^ and also the sulphate of copper.

Early in December (5lh) Hagan complained much of nausea, loss of appe-

277

Hays’s Report of Cases Treated in Wills Hospital,

tite and general feelings of malaise. His diet was then changed. Soups
which had previously constituted the principal part of his food were for-
bidden, and a little meat allowed daily with soft boiled eggs, rice, and milk.
The following pills were also prescribed. R. pulv. rhei 3j. bicarb, sodae 9ij.
extr. gent. ^ss. M. Ft. pilul. xl, three to be taken morning and evening.
These pills were continued for several days when he was given the sulphate
of quinine in small doses. Under this treatment his stomach recovered its
tone. The vinum opii was continued.

By the 1st January 1839, when my term of service expired, Hagan was
able to distinguish the different persons in the house. The granulations had
entirely disappeared, there were but few red vessels in the conjunctiva, and the
colour of the iris could be distinguished around the circumference of the cornea.

During the month of May, 1839, we had charge of the house in consequence
of the indisposition of our colleague Dr. Fox, when we found Hagan still there,
and with improved vision. My immediate successor Dr. Isaac Parish had
removed portions of the conjunctiva around the cornea which seemed to have
promoted absorption of the lymph on the cornea.

Hagan could now see sufficiently well to make himself useful by working
in the garden. The seton was still in his neck and discharging freely. A
drop or two of the undiluted liquor plumb, subacet. was directed to be placed
on his eyes every two days and iodine, to be given internally. In a couple
of weeks his mouth became sore, which was, he says, the case whexi he took
this last previously, and it was discontinued and an astringent wash directed
for his mouth under which the ulceration began to heal.

The most rapid improvement look place during this month, principally
attributable, I think, to the use of the liq. plumb, subacet. and on the first of
June, when Dr. Fox resumed the service of the hospital, Hagan was able to
read large letters — as the heading of a newspaper.

Remarks. The liquor plumbi subacetatis of the old London Pharma-
copeia is a most efficacious remedy for the removal of opacities of the cornea,
whilst the pure article at present prepared, in our trials, has proved valueless
and sometimes we have thought even injurious,

T. R. Colledge Esq., President of the Medical Missionary society in China,
well known for his eflforts to extend to the Chinese the benefits of medical
science, and whose experience in diseases of the eyes has been very exten-
sive, informed us last winter, during a visit with which he favoured us at the
Hospital, that such also was the result of his observation.

Case, Acute Inflammation of the Conjunctiva^ supervening upon
chronic — Thickening of the Conjunctiva of lower lids — Growth of Hairs
from inner edge of tarsus. Mary Lenox, aetat. 35, admitted October 3d.
The conjunctiva of the globe much injected, and that lining the lids red and
thickened. A purulent secretion, in small quantity, flowed from the eyes,
and a row of hairs grew from the inner edge of the lower tarsi and were ap-
plied to the eye, adding much to the irritation. This woman was at service
No. XLVIII. — August, 1839. 24

278 Hays’s Beport of Cases Treated in Wills Hospital,

as cook, and suffered from frequent attacks of inflammation of the eyes.
The present acute attack of inflammation was attributable to cold taken a few
days previously. Her general health was good. The irregular hairs were,
at once, carefully removed with forceps. Twelve ounces of blood were
drawn from the arm and a purgative ordered at bed time.

She subsequently underwent a pretty active antiphlogistic treatment,
consisting in venesection, cupping, purging and tart, antim. in small doses;
and at each visit her eyelids were carefully examined, and whenever irregu-
lar hairs were detected they were extracted. By these means the active
inflammation was subdued.

The palpebral conjunctiva remained, however, thickened, and the secre-
tion of the meibomian glands was deranged and in excess, and formed a
crust at the root of the lashes of the lower lid. To relieve the former, the
solid sulphate of copper was applied every other day to the part, and for
the latter, the ung. hydrarg. rub. was ordered to be rubbed at night on the
edge of the lids.

Under this treatment rapid improvement took place, and she was dis-
charged, November 10th, as a patient, and hired as a cook in the house.
She has since become principal nurse, and suffers no inconvenience from ,
her eyes, except when irritation is caused by the growth of irregular hairs.
On such occasions she has applied to me to remove them, and I have found
nothing further required for her relief. The appearance of the eyes and lids
are perfectly natural, except that the lashes are scanty.

Jlemarks. We have been induced to relate the preceding case in order
to draw attention to the fact of inflammation being often maintained by the
irritation caused by irregular hairs. These hairs are sometimes so fine,
that they can only be seen in a good light and by the aid of a lens, and yet,
they keep up excessive irritation, when not removed, to the great perplexity
of the practitioner and distress of the patient; in one instance I knew an
eye, destroyed by the irritation caused by a single hair. It occurred in a
young gentleman who was convalescing, favourably, from an extremely
severe, purulent conjunctivitis. He experienced the sensation of a hair,
irritating one of his eyes, and desired his room-mate, a student of medicine,
to remove it, as he had often seen me do. An examination was made for the
purpose, but the source of irritation could not be discovered, and the patient
was persuaded that the sensation was deceptive. On my visit, two days
afterwards, I found the eye to my surprise greatly inflamed. By the aid
of a lens, the hair, which had produced this, w^as readily seen, and was
extracted with a pair of forceps. The sensation immediately ceased, but
the eye never recovered from the consequences of the re-excitement of inflam-
mation in it.

Case. Caustic Lime accidentally applied to Cornea — Partial adhesion
of Conjunctiva of lower lid to that of the globe of the eye — Granular
Lids^ ^c. — Bernard M’Manus, eelat. 23, admitted June 16th. This man

279

Hays’s Report of Cases Treated in Wills Hospital,

when he cam^e under my care, October 1st, had dense central opacity of the
cornea of the left eye, covering the entire pupil; the lower lid was adherent
in part to the globe, the upper lid was highly injected and granulated; the
conjunctiva covering sclerotica was moderately injected; there was profuse
lachrymation and considerable photophobia; eye lashes encrusted with'
secretion from meibomian glands.

He stated that this train of evils had resulted from some lime having
fallen in his eye. He had been subjected to an active antiphlogistic treat-
ment and an attempt had been made to separate, with a knife, the lid from
the globe; but reunion could not be prevented.

I scarified the conjunctiva of the upper lid; it bled freely; cups were
repeatedly applied to the head and back of the neck; mustard pedeluvia,
blisters and purgatives, as revulsives, were next resorted to; the eye was
washed with weak chamomile tea with a little opium dissolved in it; and
finally, three grains of blue mass every night for several weeks, until a
slight coppery taste was perceptible, with syrup of sarsaparilla and ung.
hydrarg. rub. to the roots of the eye lashes at bed time.

Under this treatment the irritation of the eye was overcome, and when
my tour of duty expired, his eye was nearly well. The most troublesome
symptom in this case, was the profuse lachrymation. This came on at
irregular periods, and was alw^ays attended with severe pain in the temporal
region and forehead. Cupping, with mustard pedeluvia and the chamomile
tea seemed to afford most relief. Subsequently 1 inserted a seton in his
neck, from which I have no doubt he has found benefit.

Remarks. Adliesion of the palpebral to the ocular conjunctiva fre-
quently results from the introduction of caustic articles into the eye; and in
some rare cases, from severe purulent conjunctivitis. One example only of
this last has come under our observation. The subject of this was Henry
Seabold, aetat. 26, a farmer, from Montgomery county, who applied to the
Pennsylvania Eye Infirmary, February 15th, 1822. In this case, there
was complete adhesion of the whole palpebral to the ocular conjunctiva, the
bands extending entirely over the cornea. Vision was completely destroyed.
This condition had followed, according to the representations of the patient,
common catarrhal ophthalmia. We attempted to separate the lid from the
ball, but found it impossible to prevent reunion, though various expedients
were adopted for the purpose. In a case of partial adhesion of the upper
lid to the cornea, in a young man, a plasterer, the consequence of the acci-
dental application of caustic lime to the eye, which came under our care, in
December, 1837; repeated attempts had been made by another surgeon, to
separate the adhesion with the knife, with like w'ant of success. We
refused to repeat the attempt. The result in these three cases, would seem
to show that little was to be expected from dissecting apart these adhesions;
and we do not think we will again make the attempt. Mr. Middlemore,
however, speaks of this operation in terms which lead us to infer, though

280

Hays’s Beport of Cases Treated m Wills Hospital,

he does not positively say so, that he has performed it with success, where
the adhesions were limited to a small surface.*

Wounds of the Eye. Several interesting cases of these were admitted,
three of which seem to us to deserve to be recorded.

Case, Spines of a Chestnut — Bur penetrating Cornea, — James M’Gin-
nis, aetat. 12, was admitted November 10th, 1838. About six weeks pre-
viously, he was engaged with another boy in obtaining chestnuts, and whilst
looking up, a bur fell from the tree and struck him in the eye; some inflamma-
tion followed, which not yielding entirely to domestic remedies, and the vision
of the eye being impaired, his mother brought him to the hospital. Four-
teen or fifteen spines of the chestnut bur were observable in the cornea,
through which coat several of them had penetrated, and there was conjunc-
tival redness, but much less than might be supposed from the presence of
so many irritating bodies. With the point of a cataract needle, three of the
spines were extracted; the eye then became so irritable, and filled with tears,
and the blood vessels injected, that I thought it best to desist, for the pre-
sent, from further efforts. He was ordered sal. Epsom §j; half to be taken
at once, and the remainder the next morning. Two days afterwards, the
redness and irritability had subsided, and I extracted two more spines; when
I thought it prudent to again desist, and salts w’ere prescribed as before. By
pursuing this course, all the spines were ultimately extracted. One of these
spines penetrated the cornea, and seemed to enter the iris; its extraction
was difficult, and I only succeeded after several trials. When removed, a
portion of the aqueous humor followed. The wound healed as kindly as
any of the others, and it is difficult to discover the points where the spines
had penetrated. He was discharged October 29ih, 1838, quite well.

Remarks, The slight inflammation which resulted from this injury, is
worthy of observation. We have usually, however, found wounds of the
cornea to be attended with less inflammation than those of any other tissue
of the eye, and they readily heal, often leaving little or no perceptible
opacity. But although the cornea does not readily take on inflammatory
action, when it has once done so, and its vessels have become dilated so as
as to give passage to red blood, it is extremely difficult to overcome this
condition.

A very" common accident to iron turners, is the partial penetration of the
cornea by small particles of iron. One patient applied for relief from an injury
of this kind. Whilst engaged in turning a piece of iron, a minute fragment
entered his cornea, and a portion of it projecting externally, had causeil
considerable irritation of the conjunctiva. It was readily removed with a
cataract needle. A dose of salts was then directed, and cold applications
to the eye. The case was not thought of sufficient importance to be

* Treatise on the Diseases of the Eye. London, 1635. Vol. II. p. 733.

Hays’s Heport of Cases Treated in Wills Hospital, 281

admitted. I met the patient a few days subsequently, and learned he had
promptly recovered, without further attention.

Case, Penetrating Wound of the Cornea — Prolapsus of the Iris, —
Rosannah M’Nally, aetat. 8, was admitted November 8th, 1838, with pro-
lapsus iridis of the right eye. About two weeks previously, whilst attempt-
ing to untie a knot in her shoe string by the aid of a fork, the instrument
slipped, and a prong penetrated the cornea of her right eye, towards the
lower and outer portion, at about a line and a half, or two lines from its
junction with the sclerotica. Some inflammation followed, which resisted
the homely applications made and continued when admitted in the hospital.
The iris at this time protruded, forming a small dark tumour, and the iris
was drawn towards the wound, rendering the pupil oval.

The inflammation was first subdued by venesection, saline purgatives
and the usual antiphlogistic treatment; and the prolapsed iris was then
touched with nit. argent. Under this treatment, the prolapsed portion of
the iris disappeared, the wound healed, and the patient was discharged
cured, on the 19th of December. There remained, however, permanent adhe-
sion of the iris to the cornea, at the seat of the wound, and the pupil was
irregular. Her sight was, however, excellent, and the motions of the iris,
though limited, were not entirely destroyed.

Penetrating Wound of the Cornea by Fragment of a Percussion Cap, —
Jeremiah Holmes, aetat. 32, mechanic, admitted December 15th, 1838.
About six weeks previously, whilst standing near a person who was firing
a fowling piece, a fragment of a percussion cap flew into his right eye,
passed through the cornea near its centre and penetrated the lens, in which
it probably lodged. When admitted, the wound in the cornea had healed,
the lens had become opake, and there was considerable conjunctival inflam-
mation, with lachrymation and photophobia. This last prevented his
attending to his business, as his other eye suffered from sympathy.

By bleeding, cupping, purging and the usual antiphlogistic treatment, the
inflammation and other unpleasant symptoms were relieved; and as the
weather was unfavourable for an operation, tlie sight of the other eye was
now perfect and the patient was anxious to return home, he was discharged
December 26th, with the advice to return and have an operation performed
should he suffer any further inconvenience from the presence of the foreign
body in the eye.

In April last I heard from the physician, who had recommended this
patient to me, that he was working at his business, and the only inconve-
nience he experienced, is from the loss of vision in the one eye.

Remarks, Wounds of the eye by small projectiles, as portions of per-
cussion caps, small fragments of stone, &c., are, judging from our own ex-
perience, of frequent occurrence, and practitioners do not seem sufficiently
impressed with the importance of promptly removing such bodies. Some
years since, (1833,) a man applied to us with a slender fragment of stone, about

24*

282

Hays’s Report of Cases Treated in Wills Hospital.

half an inch long in his eye, one end penetrating the lens and the other pro-
jecting beyond the cornea. He stated that the accident had happened several
days previously whilst he was engaged in quarrying stone. A blast had
prematurely exploded, projecting the fragment into his eye. He was im-
mediately taken to a physician, who prescribed a dose of salts and the
application of cold water to the eye, but declined extracting the foreign body,
saying, “ it must fester out.” The patient’s sufferings became so intolerable,
that he resolved to come to the city for relief. The condition of the eye
when we saw him, some days after the accident, may be readily imagined.
It was inflamed in the highest degree. The foreign body was immediately
seized with forceps and was readily removed, except a minute fragment
which broke off in the lens, as it afterwards appeared; and by a most active
antiphlogistic treatment, the eye was saved, with however a small permanent
opacity of the cornea and complete opacity of the lens.

It may be stated as a general rule, that foreign bodies projected into the
eye should be immediately removed. The only exceptions to this, which
occur to us, are when the body is very small and of iron, and has entered
the anterior chapiber without wounding the iris, or when it is nearly or
completely buried in the lens. In the former instance it may be removed
by absorption, as has several times happened, and in the latter, it would
appear from our experience, not to be productive of any general irritation,
and though opacity of the lens follows, this is not to be prevented; the lens
may be removed at a more favourable opportunity, if desirable.

The means by which foreign bodies are to be removed from the eye,
must of course be in some degree regulated by the extent of the injury— -the
parts implicated — the situation of the body — and the period after the injury,
that the patient is seen by the physician. If the foreign body has penetrated
the cornea without the whole of it passing through tliis coat, it should be
extracted with a cataract needle; or if a portion remains exterior to the cornea,
it may be seized with the forceps. In t(ie latter case, it may be occasionally
necessary to first enlarge the wound, with the point of a cataract knife or
needle.

If the foreign body has passed entirely into the anterior chamber, pene-
trating or not the iris, and the wound in the cornea has not united, this
wound should be sufliciently enlarged with a cataract knife, or what we
prefer, scissors with a probe point, and the body removed with a pair of
delicate forceps. If the wound in the cornea has united, this coat may be
opened, as in the operation for the extraction of cataract.

When the foreign body is completely imbedded in the eye, and cannot
be seen, as is sometimes the case, its removal is difficult, and for the most
part the accident is fatal to the organ. A case of this kind occurred several
years since under our observation.

A man applied to us with a wound penetrating tlie cornea near its
margin and implicating the iris. He stated that, in discharging a de-

Hayward’s Case of Vesico-vaginal Fistula. 283

fective fowling piece, a portion of the percussion cap had struck him in
the eye; that immediately a quantity of fluid had run out, but whether,
or not, the fragment had come out also, he could not say. At this lime
several hours had elapsed since the accident; the eye was intensely inflamed,
excessively painful and vomiting had several times occurred. The eye was
in no condition for such an examination, as could alone have enabled us to
ascertain the presence of the foreign body, if indeed, such an examination
would have under any circumstances been allowable. The patient was,
therefore, subjected to a most active antiphlogistic treatment. By these
means the symptoms abated in a few da* s, when the patient insisted upon
going home, a few miles in the country. The pain and inflammation, how-
ever, though lessened, never entirely ceased, and frequently became severe,
and a physician in his neighbourhood very properly inferred, that this wa§
owing to the presence of a foreign body, and as the eye was then completely
disorganised, he opened it by a section with a cataract knife. The aqueous
humour, the lens which was opaque, and vitreous humour were all evacu-
ated. With the last portion of the latter came the fragment of percussion
cap. It probably had been in contact with the retina; whence the pain and
irritation. The want of perfect certainty, that the fragment was still in the
eye and some hopes, if there, it might be buried in the lens, where its pre-
sence would be productive of no farther mischief, than causing opacity of
this part, deterred us from having recourse to this expedient in the first
instance. Had it been then done, it would have saved the patient much
pain and suflTering, nevertheless we should never have recourse to so severe
a measure, except under the most desperate circumstances.

We intended to relate several other cases in order to illustrate some
of the other forms of disease of the eye, but are induced to postpone
doing so for the present, by the fear of extending this paper beyond proper
limits.

Article II. Case of Vesico- vaginal Fistula, successfully treated by an
Operation. By Geo. Hayward, M. D., one of the surgeons to the
Massachusetts General Hospital.

A PRETERNATURAL Opening between the bladder and vagina, known by
the name of vesico-vaginal fistula, is one of the most distressing accidents
to which females are liable. Its most common cause is protracted labour,
in wdiich the head of the child has been allowed to press for a great length
of lime on the bladder, when that organ is distended with urine. Gangre-
nous inflammation is in this way produced; a slough forms, which separates
in a few days after delivery, and through the opening thus made, the urine

284 Hayward’s Case of Vesico-vaginal Fistula,

is destined to pass, in most of these cases, during the residue of the patient’s
miserable existence.

Though this is, without doubt, by far the most common cause of vesico-
vaginal fistula, it may occasionally be produced in other ways. It may be
the result of a careless use of instruments in the delivery of the child; as
when the bladder has been torn by a crotchet; or it may arise from an
abscess, a stone in the bladder, or a disease of that organ.

Whatever may be the cause of the fistula, the consequence is in the ma-
jority of cases of the most afflictive kind, not only because all the urine
passes through this new opening, biU because the patient has no power of
retaining it: she is rendered miserable by the excoriation and soreness that
are thus produced, and loathsome to herself by the fetor of the urine. So
wretched is the condition of patients of this class, that the language which
Diefienbach applies to them, can hardly be thought to be exaggerated.
“ Such unhappy beings,” he says, “ are forced to exclude themselves from
society; the very atmosphere surrounding them is polluted by their pre-
sence, and even their children shun them; thus rendered miserable, both
morally and physically, they yield themselves a prey to apathy; or a pious
resignation alone saves them from self destruction.”

The degree of suffering, however, is not the same in all cases; the difference
arises from the part of the bladder in which the fistulous opening is situated.
When it is high up, the patient has some power of retention, but even then
the urine escapes through the opening, when any considerable quantity
accumulates in the bladder. But if the fistula is lower down, at the place
where it is usually found, about an inch to an inch and a half from the
opening of the urethra; the retentive power is almost if not altogether lost,
the urine flowing off as fast as it is deposited by the ureters.

So great have been the inconvenience and suffering to which patients of
this class have been subjected, that the attention of surgeons has long been
directed to this formidable trouble, but it is not till within the last twenty
years, that any operation for its radical cure has been successfully performed.
It is only ten years since, that Mr. Henry Earl remarked, “ it must be
confessed, that under the most favourable circumstances, these cases present
the greatest obstacles, and are certainly the most difficult that occur in sur-
gery.” He succeeded, however, in perfectly restoring three such cases;
“ in one of which,” he says, “ I performed upwards of thirty operations
before success crowned my efforts.”

The obstacles to success are numerous and must be apparent. The
narrow space in which the operation is to be performed, the disposition of
the urine to pass between the lips of the wound, the proximity of the ure-
ters, the great secretion of mucus by the inner coat of the bladder, which
is well calculated to interfere with the union of the parts, and the want of
readiness with which mucous surfaces take an adhesive inflammation, are
all very likely to defeat almost any operation, however well it may be done.

Hayward*« Case of Vesico-vaginal Fistula. 2>85

•Seyeral modes have been devised of operating for the radical cure of the
vesico-vaginal fistula. Dupuytren recommended, where the opening was
small, the application of the actual cautery; in his hands, it is said to have
occasionally succeeded, but with other surgeons it has almost uniformly
failed. The objections to it are numerous, and to my mind, decisive. It
is not easily applied; it is difficult, and sometimes impossible to limit its
action, and if this be not done, the orifice is enlarged instead of being closed,
and the trouble of course aggravated.

When there is a laceration only of the bladder, without loss of substance,
union, it is said, has sometimes been effected, by keeping a catheter in the
bladder, and thus preventing the flow of urine through the wound. But
cases of this kind are rarely so favourable, as they usually arise from a
sloughing of the organ, followed by a loss of a portion of its parietes. In
these cases it has been preferred to use the ligature, the edges of the open-
ing being previously pared. In a few instances this operation has suc-
ceeded; in many it has failed, and in some cases it has been productive of
inflammation, which terminated in death. For these reasons, as well as
because I am not aware that the operation has been ever before successfully
done in this country, I shall give the history of the case and the mode of
operating at some length.

Case. A married lady, aetat. 34, and of good health, consulted me on
account of a vesico-vaginal fistula. Fifteen years ago, she was delivered,
by means of instruments of her first child, which was dead, after having
been in labour three days, during all of which time she passed no water.
About ten days after her delivery an opening formed bet.\een the bladder
and vagina, and since that period she has lost the retentive power of the
bladder, and all the urine has escaped through the opening, except when a
catheter has been introduced. Occasionally when in a horizontal posture
there would be no escape of urine for two or three hours, though usually
there was a continuous flow, but when in an erect position it was constantly
dribbling, causing great inconvenience and distress. She had been eleven
times pregnant since the accident, but had never gone her full period since
the birth of her first child. It is not improbable that the fistula might have
had some influence in the production of these repeated abortions.

The only attempts that had been made to relieve her, consisted in the
introduction of a catheter, which she wore for a considerable length of time,
and touching the edges of the opening with causticp Neither of these
means afforded any relief; of late nothing had been done and she regarded
her case as almost hopeless.

Upon examination, I found the fistula situated from an inch and a quarter
to an inch and a third behind the urethra, a little on the left side. It was
not large, barely sufficient to admit the end of my forefinger, and surrounded
by a hardened edge, nearly of the consistence of cartilage. There was

286

Hayward’s Case of Vesico^vaginal Fistula,

some degree of morbid sensibility in the lining membrane of the vagina, so
that an examination was quite painful.

I told her that an operation for the difficulty had been several times suc-
cessful; that it had more frequently failed, and that in a few instances it had been
followed by very serious consequences. At the same time, I regarded her case
on the whole as a favourable one, and if, after this explanation, she wished for
an operation, I would cheerfully undertake it. She at once consented, and
it was fixed for the next day but one. May lOlh, 1839, when it was per-
formed in the following manner, in the presence of my friends Drs. Chan-
ning, C. G. Putnam and J. B. S. Jackson.

I'he patient was placed on the edge of a table, in the same position as in
the operation for lithotomy. The parts being well dilated, I introduced a
large bougie into the urethra and carried it back as far as the fistula. In
this way I was able to bring the bladder downwards and forwards, so that
the opening was brought fairly into view. The bougie being then taken by
an assistant, I made a rapid incision with a scalpel around the fistula about
a line from its edges, and then removed the wdiole circumference of the ori-
fice. As soon as the bleeding, which was slight had ceased, I dissected up
the membrane of the vagina from the bladder all around the opening, to the
extent of about three lines. This was done partly with the view of increas-
ing the chance of union, by presenting a larger surface, and partly to pre-
vent the necessity of carrying the needles through the bladder. I then in-
troduced a needle, about a third of an inch from the edge of the wound,
through the membrane of the vagina and the cellular membrane beneath and
brought it out at the opposite side at about an equal distance. Before the
needle was drawn through, a second and a third were introduced in the
same way, and there being found sufficient to close the orifice, they were
carried through, and the threads tightly tied. Each thread was left about
three inches in length. I should have remarked, that I found no difficulty
in introducing the needles by the hand, the fistulous opening having been
brought so low down and so fairly in view.

A short silver catheter constructed for the purpose was then introduced into
the bladdei^ and the patient was conveyed to the bed and laid on her right
side, to prevent any urine from coming in contact with the wound. I found
her in the evening, eight hours after the operation, quite comfortable. She
had had some smarting for two or three hours; but this was soon gone; she
complained a little of the catheter; all the water flow^ed through it and was
received upon cloths. She was directed to live on thin arrow root, milk and
water and a solution of gum arabic.

In the morning I removed the catheter, lest it might become obstructed,
and alter cleansing replaced it. No water had escaped through the wound.
The patient had slept some in the night; her pain had been slight and all
her sufferings she referred to the instrument. Her pulse was good and she

287

Hayward’s Case of Vesico^vaginal Fistula.

had no febrile symptoms. She was directed to keep in the same position,
to live on the same diet and take a solution of salts early the next morning.

She went on perfectly well for five days, the catheter being removed daily.
At this time I examined her by means of a speculum. I found that the
stitches were quite firm and that the wound had apparently healed in its
whole extent. There was no oozing of water through it, though she was
then lying on her back and there was urine in the bladder, as it flowed
through the catheter as soon as I introduced it. I then cut away the stitches,
which I found by no means easy, as I was afraid to bring down the bladder
as was done in the operation, lest the wound might be torn open. The
stitches however were at length safely removed, and in doing this I was
much indebted to the assistance of my friend Dr. Putnam.

A smaller catheter was now introduced, and the patient put to bed in the
same position as before. She continued very comfortable for two days, much
more so than she had been at any time before, which she attributed to the size
of the instrument. I then renewed the catheter altogether and directed her
to introduce it every three hours, so as to prevent any accumulation of urine.
This she did till the second night, when she slept quietly for seven hours
and on waking felt no inconvenience. Twice also during this period she
passed water by the efforts of the bladder alone, so that the organ had already
regained in part its expulsive power, as well as that of retention. She now
set up, introduced the instrument less frequently and was allowed a more
generous diet.

At the end of seventeen days from the operation I examined her again;
the wound was entirely healed and apparently firm, and the soreness nearly
gone. I advised her to introduce the catheter two or three times a day for
some weeks; and on the following day she returned home by water, a distance
of nearly two hundred miles.

Every thing connected with this case proved more favourable than I had
anticipated. The operation was not difficult, nor very painful; it was fol-
lowed by no bad consequences and afforded complete relief. Perhaps the
mode in which the operation was done, may have contributed something to
its successful result. No violence was done to the parts by drawing down
with hooks the fistulous opening, as in the common mode, nor was the
bladder wounded by carrying the needles through it, which I presume is the
usual practice. I do not speak with certainty on this point, for I cannot
find that any one has given a precise description of the mode in which the
operation is to be performed. It may be inferred from the following remark
of Dieffenbach, that he carried the needles through the bladder, “ It is
enough to say,” he remarks, “ that the operation is always a dangerous one,
chiefly on account of the injury done to the bladder; the suture always pro-
ducing more or less inflammation of the edges of the fistulous opening, or of
the surrounding parts.” Now it seems to me that in almost every case in
which the ligature would be the proper mode of operating, the edges of the

288

Se wall’s Case of Wound of the Eye.

bladder can be brought in contact, without wounding that organ. The chance
of adhesion would be much greater, and the danger of inflammation incom-
parably less. By dissecting up the membrane of the vagina to a considerable
extent around the orifice and carrying the needles through this at some dis-
tance from the edge of the wound. I cannot doubt that the edges of the
bladder, which of course should be previously pared, may in almost every
case be brought into close contact.

This of course cannot be done where there is great loss of substance, but
in such cases the ligature would not alone be sufficient, and some attempts
have recently been made to treat them by the plastic method. “ This operation
consisted,” says Blandin, “ in paring the edges of the fistulous orifice, and
adapting over it an oval flap derived from the internal surface of the large labia.”
This operation, according to the British and Foreign Medical Review, has
been performed with some success by M. Jobert. In one instance “ much
inconvenience was experienced from the aftergrowth of hair in the trans-
planted flap.”

I have ventured to make these suggestions, which I do with great difli-
dence, with regard to the mode of operating, because there is no case in surgery
in which a successful operation gives more complete relief than in that of
vesico-vaginal fistula, or relieves a greater amount of wretchedness, and
because it is by no means well settled what is the best mode of treating this
distressing infirmity. The attention of so many enlightened surgeons being
now directed to the subject, gives reason to hope that an effectual remedy
will be found for this deplorable malady.

Boston^ June, 1839.

Article III. Case in tvhich a portion of a Percussion Cap was
extracted from the .interior Chamber of the Eye by an Operation.
Communicated by Thomas Sewall, M. D., of Washington, D. C.

The following case occurred in a son of the Hon. W. C. Rives, of Vir-
ginia. At the lime of the accident, Mr. Rives, being a member of the United
States Senate, was residing in Washington with his family. Alfred, the
youngest son, had but recently recovered from the measles, which was at
that lime epidemic in the city. The disease was severe, but passed off
kindly, leaving him only, as is common in that disease, with a very irritable
state of the system. He was naturally spare and delicate in his form, but
possessed an elasticity and vigour of constitution, physical and intellectual,
rarely met with in a youth of his age.

On the 7ih of March, 1838, while standing in the street, near his father’s
residence, a boy who was passing, exploded a copper percussion cap, a

289

Sewall’s Case of Wound of the Eye,

fragment of which struck the globe of the left eye, entered the cornea near
its centre, passed obliquely through it, and embedded itself in the iris to
the left of the pupil. The fragment which entered the eye, was ragged
and angular, the eighth of an inch in length, and the twelfth of an inch in
width. It extended its greater diameter from the pupil, to the circumference
of the iris, and though embedded in the iris, it was still visible in its whole
extent. Such is the history of the case, and such was the state of things
when I was hastily called by the father to visit his son, at four o’clock in
the evening, a few moments after the accident had happened. Upon examin-
ing the case, I apprised the parents of its critical nature, and of the pro-
bable necessity of extracting the metallic body by an operation, in order to
prevent the destruction of the eye, from subsequent inflammation, and
advfsed the father to step into the cars, which were about to leave for Balti-
more, and procure, if possible, the assistance of that eminent surgeon Pro-
fessor N. R. Smith.

In the meantime, the patient was placed in bed, with the head elevated,
the room darkened, a cold lotion applied to the eye, and in the course of
the evening, twelve ounces of blood were taken from the arm, and a dose
of purgative medicine exhibited. All stimulants were prohibited, and no
other nourishment allowed than barley water. The extremities, which had
become cold, resumed their natural warmth, and a gentle perspiration spon-
taneously broke out over the whole surface. Very little pain ensued, till the
lapse of thirty-six hours; when the system reacted, the pulse became full,
hard and frequent; the skin hot and dry; and the eye manifested evident
marks of approaching inflammation, accompanied with paroxysms of severe
pain. These symptoms were subdued by further bleeding, purging and the
use of Dover’s powder. Dr. Smith did not arrive in time to examine the
eye until Sabbath morning, forty-two hours after the injury was inflicted.
Upon a careful examination of the case, with all the attendant circumstances,
it was determined on to open the eye, and, if possible, extract the metallic
substance, as affording the only hope of preserving vision, or saving the
eye from disorganisation.

The patient was accordingly placed on a table of suitable height, with
the head slightly raised, and the eye exposed to the most favourable light.
Ample preparation was made to secure the patient by means of assistants,
but the youth chose to rely upon his own self control; and this was found
fully adequate without the slightest interference of the bystanders. The
operation was commenced by separating the lids and fixing the globe of the
eye by the aid of the fingers. The cornea knife was then passed in a hori-
zontal direction, into the anterior chamber of the eye, through the cornea,
near its external margin, as for the extraction of cataract, except that the
incision was less extensive. Through this incision, a pair of delicate for-
ceps were introduced, the metal seized, and by several partial turns of the
instrument, it was disengaged from the iris and extracted. A few drops of
No. XLVIII. — August, 1839. 25

290

Se wall’s Case of Wound of the Eye,

blood followed the operation; a portion of the aqueous humour was evacuated
and the cornea collapsed. The operation was performed by Professor
Smith, with an adroitness and precision which I have seldom witnessed
under circumstances far more favourable to the surgeon. It w'as only a few
minutes after the patient was placed on the table, before the operation was
completed, and he returned to the bed.

The subsequent treatment of the case for several weeks, consisted mainly
in the abstraction of all stimulants, and as extensive depletion as could be
practised with safety. All light was excluded, the room preserved of a
uniform temperature, kept well ventilated and free from noise and confusion.
No one but the mother was permitted to approach the patient, and her pre-
sence seemed always to soothe and tranquillize him; while her watchful
care and discriminating judgment seemed to anticipate every exigence, and
overcome every difficulty. The head and shoulders of the patient were kept
constantly elevated, and this position seemed essential to his ease and com-
fort, through the whole of the inflammatory stage of the case. Cloths wet
in cold water were constantly applied to the eye, and were never permitted
to become warm or dry. Blood was taken a few times from the arm; the
bowels were fully purged every day* or two with calomel, followed with
magnesia, and the pain w^as constantly subdued by the use of Dover’s
powder, or the sulphate of morphine. The diet consisted mostly of gruel
and barley water. But these articles were administered but sparingly.
After a few days, the extract of belladonna was applied twice daily to the
lids of the eye, and over the adjoining skin, with a view to prevent a per-
manent contraction of the iris, and an obliteration of the pupil, to which
there seemed a strong tendency. Great care was taken to keep up an
equality of excitement of the system, and especially to preserve a due
degree of moisture of the skin; and no circumstance seemed more essential
to his comfort, or more effectually to counteract the tendency to inflamma-
tion, than a uniform and equal perspiration. For this purpose, the tartrate
of antimony was exhibited in small doses. Whenever the skin became
dry, the pulse would become hard, and the pain in the eye return with vio-
lence. For about ten days after the operation, the inflammation continued
to increase; from this time, it gradually declined, but was not entirely sub-
dued till the end of the seventh week. During the whole of this period,
the diet was entirely vegetable, and of the most bland and innutritions cha-
racter. Barley, rice, potatoe and cracker, with a little currant jelly and
water were allowed, but were taken very sparingly. After the first week,
calomel was exhibited in alterative doses of half a grain, till the mouth
became slightly affected. After this, calomel in three grain doses was
exhibited twice in the week, and purged off with magnesia. During the
period of active inflammation, so much coagulable lymph was effused from
the edges of the wounds in the cornea, and particularly that inflicted by the
fragment of the percussion cap, that nearly the whole of the cornea became

291

Sewall’s Case of Wound of the Eye.

white and opaque, and the anterior chamber of the eye appeared as if filled
with tlie same substance, and there seemed but little prospect of the restora-
tion of the function of vision; but as the inflammation subsided, the lymph
was gradually absorbed, leaving only one or two slight specks indicating the
position of the wounds in the cornea. Vision, though still imperfect in the
affected eye, is so far restored, as to enable the youth to see all large objects
that are passing, and to read letters of large size; and the structure of the
eye is so perfect, that scarcely any difference is observable between the
two organs, without a careful inspection.

As the case is a novel and interesting one, I shall here subjoin the letter
of Mrs. Rives, in answer to one I had written her. Although it contains
some things which I have mentioned in my communication, it will be read
with interest on account of the intelligence which it manifests, the beautiful
simplicity of the style, as well as the importance of the circumstances which
it details.

Castle Hill, November \5th, 1838,

' Dear Doctor: — I had the pleasure of receiving your kind letter a few days ago,
and take the earliest opportunity of thanking you for this added proof of your
remembrance, as well as answering your inquiries respecting our little boy Alfred.
I wish, very much, that you could yourself see the condition of his eye at present,
that you might be able to judge of the improvement it has made, and to decide
whether there is any hope of farther amendment; for though during a month after
our return home, the improvement exceeded our expectations, it has, since that
time been eo slow, as to be hardly perceptible, I think at this time that the in-
jured eye is free from any inflammation, and he raises the lid as easily as the other.
The cornea is clear except a white spot around the cicatrice where the metal was
extracted, and a white streaky which extends from this spot, and still obscures the
lower part of the pupil. The pupil is decidedly smaller than the other and seems
to me not exactly in the centre, but rather nearer the lower part of the eye. He
can distinguish letters of a tolerably large size, though he seems to find great
difficulty in reading words. Sometimes in looking at the moon, or the flame of a
candle, he says they appear differently from what they do to the other eye, and
often says “the moon looks long instead of round.”

It will give me much pleasure, dear sir, to answer your queries respecting the
treatment of the little boy, as far as I remember it, and I dare say I may be able
to refresh your recollection of the matter, as it left an indelible impression on my
mind. The sorrow and trouble caused by so alarming an accident, as well as the
kindness manifested towards us both by yourself and Dr. Smith, will never be
obliterated from our remembrance.

The accident occurred in March last, as you remember. The little boy, then
just seven years old, was with his elder brother, near the door of our house in
Third street, when a lad passed by, and stopping for a moment, exploded a per-
cussion cap on the pavement by striking it with a stone, A considerable fragment
of the cap flew in our little boy’s left eye, entering the cornea below, and passing
across a part of the pupil, lodged on the iris beneath the cornea; presenting the
appearance of a metallic substance on the face of a watch beneath the crystal.
This occurred at four o’clock in the afternoon, we immediately requested your
attendance; you came and brought instruments with you; but after examining the
eye, advised us to send for Dr, Smith. Mr. Rives immediately took a seat in the
Baltimore car which left Washington at five o’clock. By your direction the little
boy was put to bed, without his dinner, though he asked for it several times, as
he appeared then to suffer little pain. You then bled him, and advised me to give
him a dose of purgative medicine, which I did. During that night and the follow-

292

Se wall’s Case of Wound of the Eye.

ing day he remained quietly in bed; the room darkened very much. The evening
of the day after the accident occurred (Saturday) Dr. Smith came; he had been
detained in Annapolis, and could net come sooner. The day had been so very
dark, that if he had been with us, he said an operation of so delicate a nature
would have been impracticable. Through the mercy of Divine Providence the
ground was, on the night of his arrival covered with snow, which afforded the
most perfect light without the glare of the sun, which was still obscured. That
night (Saturday) the little boy slept tolerably well, until about daybreak, when
he complained of a shooting pain through his eye, which he described as a pin
sticking through it, the pain appeared severe, and returned at intervals, lasting
only a short time. At nine o’clock Sunday morning Dr. Smith and yourself came.
The Dr. for the first time had an opportunity of examining the injured eye, and
my watchful and inquisitive glance detected, I thought, disappointment and appre-
hension. His consultation with you lasted an hour, when he determined on ex-
tracting the metal. The little boy was extended on a table, and a formidable array
of assistants provided to hold him. You~doubtless remember how unnecessary
these preparations were; with what firm quietness he submitted to the operation.
I held his head, and though my eyes were closed, I felt him turn again to the Dr,
to extract the metal with the forceps after the incision was made. A very small
quantity of blood flowed from the wound, not more than one or two drops, which I
think the Dr. said gave him hopes that the iris was not materially injured. After
the operation, the little boy was again put to bed, and the room was kept very dark
and very quiet. My presence seemed to tranquillise him, and I watched over him
day and night. During all that day and night he complained much of the pain in
his eye; sometimes the paroxysms were very violent, and at last became so dis-
tressing that you directed anodyne powders to be given him whenever he suffered
great pain. I continued their use for several days and nights. I think during this
time he was bled twice; and took several doses of calomel followed by magnesia.
His diet was of the lightest kind, and happily for several days he seemed to have
no appetite, and sometimes complained of nausea. A slight draught of milk and.
water, a little currant jelly and water, or a few mouthfuls of rice without butter,
was all he took for several days. The Dr. advised the use of the belladonna, im-
mediately after the operation. I tried it several times, but it seemed to aggravate
the pain to so violent a degree that you advised me to discontinue it for a while;
this I did until the pain subsided and then recommenced the use of it. A few days
after the operation, you gave him small doses of calomel, 1 think half a grain twice
a day; which was continued nearly a week, when his mouth became slightly af-
fected, "and it was then discontinued. After that time you gave him three grains
of Calomel twice a week, followed by magnesia. In about a fortnight you tried
some of the nitrate of silver, but after dropping it once or twice in the eye, dis-
continued it. I think you said it increased the inflammation. Dr. Smith then
recommended the useof Dupuytren’s powder; consisting of calomel and loaf sugar
and this blown into the eye; this was done once in two days, and the belladonna
used twice a day, by rubbing it on the outside of the eye. I cannot speak of the
progress of the inflammation, or the appearance of the eye, as I could never sum-
mon resolution to look at it during this time, but you doubtless remember i^ ap-
pearance.

During the confinement of six weeks to a dark room, he complained of nothing
but the pain occasioned by this accident. He was sometimes nervous, and I used
every precaution during this time, to avoid all excitement, particularly any inter-
ruption to his sleep. When he was awake I was always with him, and amused
his mind by talking with him, reading his favourite little books, and soothed him
to sleep again by singing the little nursery hymns he loved to hear. I never per-
mitted him to be irritated, alarmed, or disturbed. He was always kept quiet,
calm, and as far as his situation admitted, happy. In my endeavours to this end,
I was blessed by the aid of an unseen and benignant power; and you may, perhaps,
remember some of these sweet dreams of which he used to tell us, and which proved
that though deprived of light, that “ offspring of heaven first born,” it was permit-
ted to him to “ see and tell of things invisible to mortal sight.”

During the two months we spent in Washington, great attention was paid to his

293

Sewall’s Case of Wound of the Eye,

diet, which was lig'ht and spare; a few grains of calomel given twice a week and
followed by magnesia. His health seemed unimpaired, though he became very
pale and thin. When we returned to our residence in the country, the change of
air seemed to revive him entirely; and though the diet and medicine and daily use
of Dupuytren’s powder and belladonna were continued, he gained rapidly in flesh
strength and colour, which he attributed to “ smelling the roses, and hearing the
birds sing, and feeling so glad.” We have ever since our return used many of
the precautions you advised. When he goes out, even now, his injured eye is
shaded from the light; I make occasional use of the powder and belladonna to the
eye and pay great attention to his general health.

I remain, dear sir, with the highest respect and esteem, yours truly.

J. I. RIVES.

Dr. Sewall.

JRemarks. From a slight examination of the foregoing case, it might
appear to present but little more danger or difficulty, than that of an ordinary
operation for the extraction of cataract; but upon a closer inspection, it will
be found to involve circumstances widely different, and to present some
points critical in their nature, and worthy of special attention.

1. It should be recollected that there was but little opportunity in this
case, to prepare the system for an operation, by previous depletion and low
diet, as in that for cataract.

2. We had to encounter not only the inflammation occasioned by the use
of the cornea knife, but that also caused by the ragged fragment of a per-
cussion cap, forcibly driven through the cornea, producing a contused and
lacerated wound; and in addition to these, the inflammation resulting from
the injury done to the iris, by the metallic substance, which was so embedded
in its texture, as to require considerable force to disengage it.

3. It became a point of serious deliberation, and one of the greatest
moment to decide, whether it would be possible to preserve the eye, either
in its structure or function, without the extraction of the foreign substance;
and whether the inflammation which would necessarily result from such an
operation, would be more hazardous to the organ than the irritating influence
of the metallic body embedded in the iris. No case of a similar character
could be found on record at the time, to aid the judgment upon this point;
but to show the correctness of the decision which was made, I would men-
tion that Professor Smith has since met with a case strikingly similar, in
which a portion of a percussion cap was permitted to remain in the eye of
a youth, in contact with the iris; the consequence of which was ruinous,
both to the structure and function of the organ. In this case, the metallic
substance ultimately worked out through the sclerotic coat, by the process
of ulceration, and was finally extracted, after severe and protracted suffering.
The difference in the result of these two cases, therefore, would seem to
furnish a strong indication in favour of the extraction of foreign substances
lodged in the eye under similar circumstances.

4. Depletion by the lancet, frequent purging and low diet, the exclusion
of light, the elevated position of the head, the constant application of cold

25*

294

Warren’s Case of Sudden Death.

water to the eye, the use of antirnonials in equalising and subduing the
excitement, and in promoting perspiration; and anodynes in doses sufficient
to allay the pain and tranquillise the system, were the principal remedies
relied on during the period of active inflammation; and their salutary
influence was obvious and striking. It was only by the assiduous applica-
tion of this course of treatment, under the administration of a judicious and
vigilant nurse, that the inflammation was controlled, and the eye preserved
from disorganisation.

5. After the stage of active inflammation has passed, the good effect of
abstinence, rest, the exclusion of light, the use of laxatives, and alterative
doses of calomel, was evident in removing the remaining inflammation and
in promoting the absorption of the lymph which had been deposited in the
cornea and anterior chamber of the eye. At the end of two weeks from the
time of the accident, scarcely any one would have supposed it possible from
the appearance the eye then exhibited, that vision could be restored, or even
the organic structure of the eye could be so far preserved as to present a
tolerable appearance, and yet, by the persevering application of the above
remedies, the absorption of the lymph was promoted, until scarcely a vestige
of the opacity remained, and the eye resumed nearly its natural appearance.

6. The constant and protracted application of the extract of belladonna
to the eye and the neighbouring parts, was indispensable. It obviously pre-
vented a permanent contraction of the iris, and an obliteration of the pupil,
to which there was from the commencement a strong tendency.

Article IV. Case of Sudden Death, with Remarks on that Occurrence,
By Edward Warren, M. D., of Boston, Massachusetts.

Nothing is of more frequent occurrence in the life of a physician, than
to be called in haste to a person, who is said to be “ in a fit.”

He finds, on his arrival, the friends of the patient in the utmost conster-
nation and alarm; but in this he does not ordinarily participate; because he
is aware that these are generally false alarms, and that, in nearly all such
cases, where there is no particular evidence of cerebral or cardiac disease,
the patient recovers spontaneously, and the fit leaves him in nearly his
usual degree of health. Cases of apoplexy, paralysis or epilepsy, are rare
in comparison with those of hysteria or syncope, and still more rare are
the cases that have a sudden and fatal termination.

Amidst the infinite number of false alarms, however — amidst the nume-
rous cases of syncope and hysteria, one sometimes occurs of more serious
consequence. The patient, without having previously exhibited any striking
marks of organic disease, is suddenly seized with symptoms, which appear

295

Warren’s Case of Sudden Death,

at first, only those of ordinary syncope, or of some hysterical affection, but
which bailie the expectation of the physician, and resist all his efforts to
restore animation.

A case of this kind recently occurred to me. The patient was a young
woman of very delicate appearance, aged eighteen. She was married at
fifteen, and had several times miscarried, but had no children. She was a
domestic in a private family, where she had charge of children, but was
never able to do any hard work, in consequence of a weakness at her
“ stomach.” She frequently complained that it hurt her to go up stairs.
She w'as of a lively disposition, but yet had frequently, if not habitually, a
slight degree of that anxious expression that characterizes disease of the
heart. Menstruation had always been difficult, and its occurrence frequently
preceded or attended with fainting.

For several days preceding the attack I am about to describe, she had
been in unusually high spirits, especially on the evening previous, Saturday,
which was about the time for the menses to come on. On this day,
she complained of weakness at the “ stomach.” In the evening, she
visited a friend, to whom she complained that she felt strangely — she had
no sense.” After her return home, however, she was in extravagantly high
spirits. Sunday morning, she seemed as well as usual. She ate breakfast
about eight o’clock, consisting of coffee, bread and fish — rather less than
usual. She then went up stairs about her work, and came down about ten
minutes past nine. She had reached the lower entry through which she
was passing, when she was heard to fall, making at the same time a gurgling
noise in the throat. She was found lying upon her face — her countenance
very much flushed and hot. I saw her about ten minutes after she fell.
Her face was of natural appearance, neither very red nor pale; her extremi-
ties were cold; there was gentle respiration. I immediately felt the pulse,
which I found beating with moderate force and quickness. The eyes were
closed, and the pupils slightly dilated, but in a natural position. She was
lying upon a sofa, senseless and motionless. There was no stertor; no
frothing at the mouth; no spasm. All the muscles were perfectly lax, and
her limbs and head fell in any direction they were permitted. I directed
the usual means for restoring suspended animation, to be instantly resorted
to. Volatile drops were exhibited internally; hot water applied to the feet;
a mustard poultice to the abdomen, and the temples and extremities were
briskly rubbed with volatiles.

When I first saw her, there was nothing alarming in her appearance. I
supposed it to be a common hysterical paroxysm, which might naturally be
attributed to dysmenorrhoea. The pulse, however, soon stopped, and re-
spiration ceased. The attempts to restore the latter function by artificial
means failed, and the extremities became gradually colder. The attempts
to restore animation were continued for about three hours. The body was
then nearly cold; but there was not the slightest rigidity of the muscles:

296

Warren’s Case of Sudden Death.

the flexibility of all the parts continued. It is a subject of great regret,
that the patient being of an Irish family, I could not obtain an examination.

With regard to the treatment of such cases, we generally are guided by
circumstances. Where the symptoms are those of cerebral congestion, we
bleed; where there are marks of impeded respiration, we open the trachea.
In this case, there were neither. The symptoms being those of syncope,
venesection, supposing it to have been possible to obtain blood, would have
been manifestly improper. In cases of spasm, emetics, cathartics and stimulat-
ing enemata, will sometimes rouse the powers of the system, by exciting the
parts to which they are applied, and restoring their natural functions. But
when there is no action; when there is a sudden prostration of the system, an
aneantissement of all the functions at once; the two former remedies are
inapplicable. Enemata may be tried, indeed, where they can be employed
without interfering with'^other measures; but we have more to hope for, in
the first instance, from the exhibition of stimulants by the mouth, where
they can be administered, and from powerful external applications. When,
by these means, we have succeeded in exciting some slight degree of action,
we may then derive advantage from stimulating enemata. In the case in
question, supposing at first that it was one of hysteria, which is well
known to assume every variety of form, I did not consider powerful reme-
dies called for, and within a very few minutes, animation was so entirely
lost, that there could have been nothing to hope for from injections.

The excitement that she had previously displayed, her extravagant spirits
upon the evening before, and her complaint of “ want of sense,” would
seem to point to the brain as the organ in fault. On the other hand, her
frequent complaints of weakness at the stomach, by which she undoubtedly
meant her heart, would seem to point out the latter organ as the seat of
disease. Any aflfection of the heart that produced an increased impulse of
the blood upon the brain, through the carotids, would, of course, produce
cerebral excitement. Accordingly, we find that severe affections of the heart
or pericardium, are not unfrequently attended by delirium. A slighter affec-
tion, of a similar kind, will therefore produce merely a greater or less degree
of excitement, according to circumstances.

A remarkable feature in this case, was the continuance of pulsation, strong
and full at the wrist, after the loss of sensation. In common cases of car-
diac lesion, the pulse must cease almost instantly. This continuance of
pulsation might be supposed to show that the functions of the brain were
destroyed previously to those of the heart. It does not, however, follow
by any means, that this organ may not occasion the death of the cerebral
functions, (if I may use the expression,) by some sudden perversion, not by
cessation of its action, and continue to act itself for some seconds after.

In the first volume of the Medico-Chirurgical Transactions, we find a
paper by Mr. Chevalier, giving an account of three cases of sudden death,
which appear somewhat similar to that which I have described.

297

Warren’s Case of Sudden Death.

The first was that of a young married lady, who died suddenly at a very
early period after impregnation. While talking with her husband, she com-
plained of being faint, and desired to lie down. She was led to her bed,
and was supposed to fall asleep in her husband’s arms. About 20 minutes
after, he rang for the servant, who, on entering the room exclaimed — “ My
mistress is dead!” So indeed it proved.

On examination, no morbid appearances were found in any of the viscera,
but there was an extreme flaccidity of the heart, and an entire emptiness of
the cavities. There was blood in the vena cava, and in the pulmonary veins.
The auricles and ventricles were destitute of blood, without either of them

being contracted. Mr. C thinks that this lady died in a peculiar kind

of syncope or asphyxia, in which the action of the heart had ceased, from
want of a regular supply of blood from the returning vessels.

The second case, was that of an elderly man, who had recently recovered
from a maniacal affection, and who fell suddenly from his chair, breathed
short for a few moments, and then expired. The only morbid appearance,
which was found in the brain, consisted in ossification of the falx, evidently
of long duration. The state of the heart was found similar to that in the
former case. All the cavities were empty, but uncontracted, and the vena
cava was also empty to the distance of several inches from the auricle. No
other appearance could be detected in any viscus, by which death could be
accounted for.

The third case was that of a lady who died suddenly, after being delivered
of twins. After the birth of the second child she appeared a good deal
exhausted notwithstanding that the discharge of blood was very moderate.
She recovered a little, but about two hours after, grew suddenly faint; breathed
short and died in about half an hour. — All the cavities of the heart were found
in a state of relaxation and completely destitute of blood. There was no
blood in the vena cava near the heart, and the emptiness of its ascending
branch extended as low as the iliac veins.

Mr. C. remarks that he has been able to find only two cases similar,
recorded bj?- medical writers. One of these is recorded by Bonetus. It occur-
red in a woman about forty years of age, who complained suddenly of dim-
ness, noise in the ears, and headache. She soon lost her voice and pulse and
died in four hours after the attack. Not a drop of blood was to be found in
the heart or the adjoining vessels.

The other case is from Morgagni. It is similar to the third of Mr. C’s
cases. It was in a woman who, about an hour after her delivery of a daugh-
ter, was suddenly seized with dejection of spirits, coldness and loss of pulse
and died in an hour and a half from the attack. On dissection, the heart
vvas found exceedingly flaccid, scarcely any blood was found in the auricles
or the right ventricle, and none at all in the left.

Mr. Chevalier concludes his paper with an account of two cases commu-
nicated to him by Mr. Woodd, which, though not fatal, appears to be of a

298

Warren’s Case of Sudden Death.

similar nature to the former. He proposes for this affection the name of
asphyxia idiopathica.

The first patient, Mr. A., was attacked about one o’clock in the morning
with an uneasy sensation in the thorax difficulty of respiration, and a sense
of extreme lassitude. Mr. W. found him at six, with a pulse hardly per-
ceptible and not more than twenty in a minute, although the vessels of the
skin and tunica conjunctiva were loaded with blood. He had taken stimu-
lants freely, notwithstanding which, the action of the heart had decreased.
The sense of fainting and difficulty of breathing had become almost insup-
portable. He recovered under the use of stimulating medicines and ene-
mata.

The subject of the second case was suddenly seized after a long walk
with great difficulty of breathing and faintness, so as to be unable to stand or
speak distinctly. When seen by Mr. W. his face was suffused with blood,
his breathing was difficult with great anxiety, and his pulse scarcely percep-
tible. He supposed himself dying. He was relieved by the exhibition of
stimulants, aether, ammonia, and laudanum. A blister was subsequently
applied to his chest and he shortly recovered entire health.

The suffusion of the countenance, Mr. Chevalier considers as distinguish-
ing this last case from one of ordinary asphyxia, and as marking its affinity
to the others, as it showed the evident detention of the blood in the extreme
vessels.

In two of the cases communicated by Mr. C. and in the one cited from
Morgagni — very possibly in the one from Bonetus, the exciting cause of
death seems to have been in the uterine system. In the young woman I
have spoken of, death took place at the period when the menses were expect-
ed but had not occurred, and menstruation had usually been preceded by
fainting or some hysterical affection. There was by report great suffusion
of the countenance at first, though it did not continue when I saw her but
returned afterwards, since her countenance was described by one who saw
her on the next day as red and swollen. If this was true, the face was
emphysematous, and the emphysema subsequently disappeared, for on
removing the body for burial in a different place a fortnight after, it was
found perfectly fresh and free from putrefaction, and the countenance
of natural appearance.

Another cause of sudden death has been recently suggested by M.
Ollivier, to wit, the disengagement of a gaseous fluid in the blood, and its
accumulation in the heart. If this is really a cause of death, may it not be
a question whether Mr. Chevalier’s cases may not be accounted for upon a
similar principle? The heart and vessels to some distance from it, were found
empty. Now might not the air have escaped upon opening the heart, without
being perceived; or might it not have been absorbed or passed off in some
manner, after the coagulation of the blood in the vessels? But Mr. Cheva-
lier stales that the cavities were found dilated. If so, they must have been

299

Warren’s Case of Sudden Death.

filled with something, and if not with blood or other perceptible matter, of
course they must have been filled with air. The escape of air into the cavi-
ties of the heart would of course exclude the blood. Let us now see how
the description given by M. Ollivier corresponds with that of the foregoing
cases.

M. Ollivier gives three cases. The first was that of a young child who
had been affected with measles, for a few days, and seemed to be quickly
recovering from the disease, when suddenly, and without any premonitory
symptoms, he fainted and expired in the course of a minute or two. On
examination after death, the heart and large vessels were found distended
with air, the parietes of the heart emphysematous and the cavities quite
empty. The emphysema extended itself in the course of a few hours after
death, through the cellular membrane of the body. No morbid change was
found in the viscera, and there were no marks of putrefaction.

In the second case, that of a robust man, similar appearances were observ-
ed. This individual died suddenly a few minutes after he had retired to bed,
seemingly in perfect health. General emphysema appeared about twelve
hours after death; but without the slightest sign of putrefaction.

The third case was that of a young woman aged twenty-two, who was
recovering from a fever which had left her for some time very weak. One
afternoon, after having been engaged in trying on some masquerade dresses,
she laid down upon her bed, to rest herself preparatory to her evening
amusement. Upon attempting to rise and dress herself, she suddenly felt
extremely faint, her head fell forwards on her chest, she screamed out that
she was dying, and expired almost instantly.

M. Ollivier found the expression of lier features calm like that of one
asleep. The brain appeared to be quite healthy, though the blood which
flowed from the divided vessels was frothy from the mixture of air. The
cavities of the heart were remarkably distended, and, as it were, blown out.
When an incision was made into the parietes, they at once sunk down. The
lungs and all the pelvic and abdominal viscera were sound.

The peculiar circumstances of this case and its analogy to those in which
sudden death has taken place from the accidental introduction of air into a
vein, led Mr. C. to attribute it to the cause above mentioned. In these cases
a whistling sound had been heard upon the division of a vein, during a sur-
gical operation, the patient has expired almost instantly, and the heart upon
examination has been found empty of blood and distended with air, and air
bubbles found in the blood. M. Velpeau after a critical examination of the
forty cases which have been given as supposed instances of this accident,
and a comparison of them with experiments made upon animals, is disposed
to deny that there has been as yet sufficient evidence adduced that this is
really a cause of death. It must however be very difficult to imitate a natu-
ral phenomenon of rare occurrence by any artificial means. Because a large
quantity of air is found requisite in an experiment to destroy an animal in

300

Warren’s Case of Sudden Death,

the manner mentioned, it does not follow that a less quantity under certain
circumstances may not be fatal to the human subject. The small size of the
vein through which the air is said to have been admitted, is no proof, there-
fore, that it was not the cause of death. The occurrence of the sound that
has been noticed, like that of the passage of air through a narrow passage,
the state of syncope, if not of death into which the patient instantly falls,
and the emptiness of the cavities of the heart, or their distention with air
might seem to be so good evidence of the accident, as is generally attainable
upon medical subjects.

If this be admitted as an occasional cause of death, the question next
occurs, in what manner does the air find admission into the heart, where no
operation has been performed, and where the patient has suffered no external
injury? Into the discussion of this question, I do not propose to enter. It
is sufficient that Bichat and other distinguished writers maintain the possi-
bility of such an occurrence. Bichat speaks of it as instantly fatal.

I think it will be admitted upon a comparison of the cases above men-
tioned, that there are general features of resemblance between the whole of
them. One cause of fallacy in the report of medical cases, is that each
observer is apt to pay particular attention, and attribute most importance to
certain facts, especially if they correspond with his own views; while other
facts, perhaps, of more real consequence, pass entirely unnoticed. Thus,
had the first observer, whose cases I have cited, had his attention called to
the subject, he might have found reason to consider the cause of death the
same as in M. Ollivier’s subjects. Cases of death occurring suddenly
during operation, as M. Velpeau remarks, were explained in various man-
ners, and attributed to various causes, long before that of the introduction of
air through a divided vessel was suggested; but as soon as attention w^as
called to the subject, instances were speedily observed.

The cause of death assigned by Mr. Chevalier, the retention of the blood
in the extreme vessels, does not seem to be sufficient to cause the sudden ces-
sation of the action of the heart. The phenomena would be better accounted
for by attributing them to an action that would expel the blood from the heart,
and force it into the minute vessels, than to one that merely delayed the return
of the blood. Supposing the heart to become suddenly distended with air,
or suppose its action to be suddenly increased by the application of some
unaccustomed stimulus, there would be a rush of blood upon the brain,
sufficient to induce immediate paralysis of that organ. This effect might be
consistent with subsequent retardation of the heart’s action, provided life was
not destroyed by the first shock; for the effect of all stimuli is at first to
increase, but secondly to retard the action of the parts to which they are applied.
In this manner, the continuance of pulsation at the wrist for a short time
after consciousness was lost and the vitality of the brain extinct, might be
accounted for.

The case which I have recorded is incomplete, since permission could not

301

Lindsly’s Remarks on Cholera Infantum,

be obtained for a post mortem examination; still there can be little utility in
these examinations, unless they enable us to argue from the cases in which
we obtain them, to those in which we do not: nor are they of any practical
value, unless we can derive from them the information necessary to detect
the morbid cause by the symptoms exhibited in the living subject.

We find that some authors still place the cause of the most sudden and
instant death, in the brain; but it is now most generally conceded, that the
heart is most frequently in fault. In old persons, especially when symp-
toms of cardiac affection have previously existed, and where we find no
marks of cerebral disease, we may generally suspect rupture of the heart.
All the cases recorded of this lesion, however, have occurred in old people,
and it certainly is not one that we should look for in the young.

Cases of apoplexy, epilepsy and paralysis are, in general, too strongly
marked to be mistaken, but the symptoms when the heart is affected are those
of syncope or collapse.

Boston^ May lU/i, 1839.

Article V. Remarks on Cholera Infantum. By Harvey Lindsly. M. D.,
of Washington D. C.

In looking over the returns of deaths as made to the Board of Health of
the city of Washington, I have been struck with the very large proportion
of children under two years of age, and on examining into the causes of this
fatality, have remarked that, from the month of July to September inclusive,
affections of the bowels have been exceedingly numerous.

For example, it will be seen by the following table, that of the whole
number of deaths in the month of July and August nearly one half, and in
two instances more than one-half were under two years of age; and that
of this number, almost three fourths died of what is usually termed here
“ summer complaint,’’ under which general term are included cholera in-
fantum and simple diarrhoea of children. Also, that the cases were much
more numerous in July and August than in June, that a slight diminution took
place in September, and that in October the number was again very small.

1837.

Whole No, of deaths.

Under 2 years of age.

Choi. Infhai.

June

July

August

September

October

[* A notice of some interesting researches, by M. Dcvergie, on the cause of sudden
death, will be found in our No. for February, 1839. — ed.]

No. XLVIII. — August, 1839. 26

302

Lindsly’s Remarks on Cholera Infantum,

1838.

Whole No. of deaths.

Under 2 years of age.

Choi. Infant.

June

July

August

September

October

The ratio of cases of infantine cholera in the above table is about the same
as that exhibited by the record for several years past, and this may llierefore
be assumed as the proportion of victims annually destroyed by this fatal
disease in Washington, during the montfis referred to. With respect to the
accuracy of the returns, I would merely remark that they were made under
my immediate superintendance as President of the Board of Health and that
every pains was taken to have them as correct as possible, though I am
aware that implicit reliance cannot be placed upon any statistics of this
description.

In consideration of the frightful mortality of this disease, and of the immense
numbers who are thus every year hurried to an untimely grave, I believe
that the attention of the profession cannot be called too often or too earnestly
to it, that every physician may be familiar with its history and be prepared
to adopt the best known means of controlling the dreadful malady.

It is with this view simply, and not with the expectation of adding much,
if any thing, to our knowledge of the disease, or of bringing forward any new
remedial measures, that I am induced to offer these cursory remarks to the
consideration of the profession. And if I can aid in ascertaining v/ith more
precision, the relative value of the numerous therapeutic agents now in vogue
or can, in one solitary instance, prevent the wasting of valuable time in the
employment of doubtful or injurious remedies, I shall consider my labour
amply repaid.

I have, for several years past, devoted most particular and anxious attention
to this disease as it has occurred in my own family and among numerous
patients, and I feel perfectly satisfied that some at least of the ordinary
modes of treating it can be advantageously modified.

Symptoms. This disease presents considerable variety in its mode of
attack; sometimes coming on as a simple diarrhoea, which form it may retain
for several days, without nausea, pain or fever. These discharges perhaps
increased gradually in frequency: the stomach becomes disordered and
vomiting takes place. Fever now makes its appearance; the extremities are
cold; there is pain in the abdomen on pressure; the countenance assumes a
painful and harassed expression; the pulse is generally small, corded and
irritable, though occasionally more full and soft; the fever is of an exceed-
ingly irregular and intermittent character, with decided exacerbations towards
evening; while the extremities are generally cold and the skin pale denoting
a languid and deficient circulation; there are evident determinations of blood

Linclsly’s Remarks on Cholera Infantum. - 303

to the head and abdominal viscera, which become hot and burning; the eyes
often, perhaps generally, partake of this excitement, being red and fiery and
suffused with blood, though they are sometimes languid and dull, and when
the patient sleeps they are seldom entirely closed; the tongue is usually of
a brownish white, slightly furred and dry, or hard and reddish; the skin on
the forehead is tight and slicks close to the bone; the cheeks lose their ful-
ness and colour; the nose is pointed and sharp and the lips become pale and
thin; the abdomen swells from flatulency and the feel from cedema; the little
sufferer moans and tosses about continually; his perceptions are dull and he
takes little notice of surrounding objects and will scarcely be disturbed by
flies on his face or even on the eyes. As the disease advances in violence,
the thirst is most tormenting and unquenchable, and the vomiting incessant,
every thing being rejected as soon as swallowed; in the more unmanageable
fatal cases, all these symptoms are rapidly aggravated, the spasmodic action
of the bowels is communicated to the whole system, and the last debt of
nature is soon paid.

In many, perhaps in the majority of cases, cholera infantum comes on
without the premonitory diarrhoea, the little patient being seized at once,
when in apparently perfect health, with violent vomiting and purging, which
may put at defiance our best devised plans of treatment and prove fatal in two
or three days or even in one. It is not unusual, however, whether it make
its onset mildly or violently, for the vomilingto cease after a few days, while
the purging shall continue for several weeks and finally exhaust the patient,
or eventually yield to the remedial course.

The appearance of the evacuations during the progress of the complaint is
exceedingly various; there are usually little or no natural feces in the dis-
charges; these are sometimes thin and watery, sometimes more thick and
consistent; sometimes they are green, or brown, or white, or yellow; some-
times exceedingly copious and passed without pain, and sometimes very
sparing and accompanied with great tenesmus and griping; sometimes very
offensive and sometimes entirely inodorous; sometimes the food seems par-
tially or fully digested and at others it is discharged unaltered by the stomach
and intestinal canal.

The emaciation which takes place in cholera infantum is most rapid and
seems surprising, even when we take into view, the incessant evacuations
both upwards and downwards, and that hardly a particle of food is properly
digested. No matter how full and plump the child may be at the onset of
the disease, in a very few hours, the falling off becomes apparent. The
limbs, particularly, exhibit the melancholy change: the skin is dry and
rough, and the emaciation continues to advance, unless the disease be con-
trolled by remedies, or arrested by death, till the body resembles a skeleton,
having literally little besides skin and bone.

Diagnosis. Little need be said on this branch of our subject, as it is

304 Lindsly’s Remarks on Cholera Infantum,

impossible to mistake this disease for any other: and where it runs into or
resembles the analogous diseases of dysentery or diarrhoea, the treatment
should be the same as we would direct, if they had constituted the original
complaint.

Prognosis, It is extremely difficult, or rather wholly impossible for
even the most skilful and experienced physician, to do more than form a
guess at the result of any given case of cholera infantum. Scarcely any
disease is more uncertain in its duration, more variable in its symptoms, or
oftener disappoints the practitioner as to its final issue. It is often suddenly
and most unexpectedly fatal, while at other times patients recover under the
most desperate circumstances.

We may, however, usually expect a favourable result, when we find the
pulse becoming slower and fuller; the alvine dejections less frequent, and
especially when they assume a natural consistence and a brownish yellow
colour; the temperature of the skin more equable and regular, the head and
abdomen losing their preternatural heat, and the extremities their unusual
coldness; and especially when the irritability of the stomach wholly sub-
sides and the food is readily and completely digested.

On the other hand, when the symptoms* previously enumerated march
steadily onward, unrelieved by medicine and unaffected by time, we may
look for a fatal termination. In these cases, however, there is, as already
mentioned, great variety, and entire uncertainty as to the period of dissolu-
tion. Sometimes death occurs in two or three days, oftener not under two
or three weeks and occasionally the patient lingers as many months. If
the average duration of the disease could be ascertained, it would probably
be found not to vary much from eighteen to twenty days.

Pathology, Inasmuch as cholera infantum prevails extensively, and in
fact almost exclusively during the heat of the summer and autumn; as it is
most violent anid fatal in those seasons, when there is the greatest amount
of moisture combined with excessive warmth, and of course the most ex-
tensive prevalence of marsh and vegetable miasmata; as it greatly dimi-
nishes or ceases entirely on the approach of cold weather; as, in fine, we
find it to be produced by the same causes and to be co-extensive in its du-
ration and severity, with the bilious autumnal fevers of our country, it is
natural to consider it a mere Variety of this class of diseases.

That it does not arise, as some have supposed, from the irritation pro-
duced by dentition, is to my mind perfectly evident — because it frequently
occurs before that process has commenced, because it is often w'anting when
the dental irritation is greatest, and because it prevails only at particular

* Dr. Dewees in his valuable work on the diseases of children, speaks of a symptom,
which I have looked for very carefully but have never been able to find, except in one or
two cases: it is a crystalline eruption upon the chest, of an immense number of watery
vesicles, of a very minute size.

305

Liiidsly’s Remarks on Cholera Infantum,

seasons of the year. There is no doubt, however, that in children who
suffer much from this process of nature, cholera is a more dangerous com-
plaint and more frequently fatal, just as it would be from any other source
of irritation superadded to the original disease. Dentition, therefore, as
well as irregularities and imprudences in diet, and exposures to wet and
cold may be exciting and exaggerating causes of cholera — while still the
grand source of mischief — the “ causa causarum" will be found in the
long continued heat of our summer, combined with marsh effluvia.

It may occur at any time during infancy, though the most fatal period is the
second summer, and hence, the child is thought to be pretty safe if it escape
that trying season. This disease has been frightfully destructive in particu-
lar families here — -in some, as many as four or five children in succession
having been carried off by it.

The system in infancy seems peculiarly susceptible to disease, the least
irregularity in diet, or the slightest exposure to atmospheric vicissitudes,
being often sufficient to bring on a severe attack of sickness. It is not sur-
prising, therefore, under these circumstances, when we consider the" great
vascularity of the skin at this period of life, its excessive irritability, and the
intimate connection between the due discharge of its functions and a healthy
state of the abdominal viscera — that a long exposure to a heated atmosphere,
especially when loaded with miasmatic exhalations, should render the cu-
taneous vessels unequal to their task of circulating the blood; that in conse-
quence, the circulation should be diminished: the blood driven in upon the
central organs, and that diarrhoea, cholera, or inflammation of the viscera be
the speedy result.

The appearances observed on dissection fully confirm these views of the
pathology of cholera infantum. The thorax is usually found in a perfectly
normal condition: the brain in recent cases presents few or no traces of
morbid action, and although congestion and sometimes effusion, (constituting
hydrocephalus,) are observed in patients who have lingered for several
weeks, yet these symptoms can readily be accounted for on the principle of
the intimate sympathy existing between this organ and the deranged.

It is in the viscera of the abdomen that the chief traces of mischief are to
be looked for. The vessels of the liver, stomach and intestines are unduly
distended witli blood: the effects of inflammation may often be discovered
throughout the whole intestinal canal and particularly in the small intestines:
ulceration and even abrasion sometimes occur; dark purple spots may be
seen scattered over the mucous coat of the stomach and duodenum while
the large intestines are generally found in nearly a healthy condition.

The liver is almost universally engorged with blood, and in cases of long
standing greatly enlarged:* a large quantity of bile is generally found in the

* In 1836, I'dissected a child 18 months old, that had been sick ten weeks, whose
liver was so immensely increased in size as to fill very nearly one half of the abdomen.

26*

306 Lindsly’s Remarks on Cholera Infantum.

gall bladder, sometimes of a dark green colour and at others pale, or almost
white. I have seldom noticed any morbid appearances in the pancreas or
spleen: while in three or four cases in my dissections, the bladder was
quite empty and exceedingly shrivelled— -a fact, not mentioned by most
writers on this disease.

Treatment. Removal to the country in cholera infantum, like visiting a
warm climate in consumption, is considered a sovereign remedy, and one
almost indispensable to a cure, by many persons both in and out of the pro-
fession. The fallacy, not to say folly, of the idea in the one case, (in a
great many instances of consumption,) is, however, now beginning to be
realised and acknowledged; and I have no doubt that a more extensive expe-
rience, and a more accurate observation of the effects of removal to the
country in the other case, will convince the most credulous, that its bene-
ficial effects have been vastly overrated.

Let me not be misunderstood. It is highly probable, perhaps certain,
that in the narrow, crowded and filthy streets of some parts of our large
cities, children aft’ected with cholera would be benefitted by a removal to the
country, where they might breathe a purer air, obtain a more healthy and abun-
dant supply of food, and enjoy better opportunities for invigorating exercise.
But, unfortunately, the people occupying such parts of our cities, are, as a
general rule, the very persons whose straitened circumstances forbid their
adopting this, to them, important remedy.

The practical question then recurs, how far it is advisable for those who
reside in airy, well ventilated houses, with all the comforts, and perhaps
luxuries of life at their command — with the facilities of having their children
carried out every day (by means of servants, carriages, &c. &c.) how far it
is advisable for them to sacrifice the thousand nameless conveniences of
home, and go into the country to be crowded into small, uncomfortable
rooms, far from medical aid, &c., is a point well worthy of mature conside-
ration. Even in such cases, however, perhaps it might be admitted if they
would seek an elevated, mountainous country, entirely free from marsh
miasmata, and with a decidedly cooler atmosphere than the one they have
left; that the change would be eminently beneficial, these latter advantages
more than counterbalancing the inconveniences before referred to.

But I do contend that the idea of going a few miles into the country,
where the temperature is precisely the same, or probably more oppressive,
from the smallness of the houses, and their being generally built of wood —
where the miasmatic exhalations are equally or more abundant — removed
from the comforts and conveniences of home — at a distance from suitable
medical advice — the idea of being benefitted by such a change, I do assert,
is perfectly preposterous, I have seen it tried again and again, by twenty
children being sent in every direction, north, south, east and west, within
twenty miles from Washington, and almost universally, they have returned

Lindsly’s Remarks on Cholera Infantum* 307

worse than they left, or have found their grave where they sought renewed
health.

The situation of Washington is, to be sure, somewhat different from that
of our large cities; and the above remarks are more applicable to it than to
them. Our streets are all very wide, a very few of them compactly built;
of course, there is no deficiency of ventilation. In addition to this, it
should be remarked that the city is more healthy than the surrounding
country; hence, nothing is gained as it respects malaria, by removing from
one to the other.*

An error, too, is not unfrequently committed in delaying the removal too
long, until the patient becomes very weak and almost exhausted, and is
entirely unable to bear without injury the fatigue of travelling. In conse-
quence of neglecting this precaution, I have known a child to be sent away
almost in articulo mortis and to die on the route, to the great grief, as well
as serious inconvenience of its friends.

If, then, a removal to the country in cholera infantum be recommended,
let a cool, elevated, healthy spot be selected, and let the change be made
before death shall have already marked the victim as his own. In those
cases, where a change of residence is not thought advisable, a very good
substitute may be found in carrying the child out every pleasant day in a
carriage, or the nurse’s arms, either into the surrounding country, or merely
in the immediate neighbourhood of its residence.

Emetics and Anti-Emetics, The first thing to be done where the dis-
ease is fully formed, that is, where nausea and vomiting exist, is, if possible,
to allay the irritability of the stomach, in order that the remedies we recom-
mend may be retained. Some physicians, perhaps a majority of those who
have written on the subject, advise that the treatment be commenced with
an emetic, whether there be nausea or not. It seems to me, that such
authors cannot have reflected on the peculiar delicacy and excessive irrita-
bility of the organ upon which they propose to operate. Late writers, how-
ever, and among them the judicious Dewees, condemn this practice. An
emetic most certainly should never be administered in this disease, unless,
upon most careful inquiry, we have ascertained that the child has taken some
improper article of food, (as raisins,) which probably is still in the stomach,

[* On reference to the writings of Drs. Rush {Med. Inq. and Obs. Vol. II.) and Dewees
{A Treatise on the Phys. and Med. Treatment of Children^ p. 426,) it will be found that
these eminent men testify to the great benefit which they have observed to be obtained in
every stage of cholera infantum, by a removal of the patient to country air; and we believe
that the experience of every practitioner of Philadelphia, is confirmatory of this state-
ment. For our own part, we are led to believe that a mere change of air is often
useful, for we have seen much advantage in some cases, where the disease, after
being cured, has recurred in the country, from a return to the eity. This of course can
only be the case where the town house is spacious and airy. — ed.]

308

Lindsly’s Remarks on Cholera Infantum.

and which may have given rise to the attack; and even in such cases, our
object can generally be accomplished by simply encouraging the vomiting
already begun, by means of warm water, or warm chamomile tea; which
may be continued until every foreign substance is discharged. If an emetic
article ever is given, it should be nothing stronger than ipecacuanha.

It is much easier, however, to keep up, than to allay the disordered action
of the stomach. I have little faith in most of the anti-emetic articles usually
employed for this purpose. I have tried them all, and generally found them
useless, sometimes evidently injurious. I refer particularly to peppermint,
lime-water, spices, toast and water, laudanum, <fec. Dewees recommends
strong coffee without sugar, or milk in teaspoonful doses as an efficient
remedy. This I have never found to answer, except in two or three cases,
partly, perhaps wholly, because it is extremely disagreeable to children from
its powerfully bitter taste; an objection, certainly in itself of no little weight,
I place much more reliance on another remedy, which he likewise recom-
mends in very strong terms, viz. an injection of a gill of warm water, in
which are dissolved two or three teaspoorifuls of common salt, to be
repeated pro re nata.

This is undoubtedly a valuable remedial measure, and will, perhaps,
effect as much and succeed as often as any single means that we have. The
slight irritation of the rectum produced by the stimulus of the salt, exerts a
powerful derivative tendency in calming the excitement of the stomach, and
I have very often witnessed its beneficial effects in adults as well as children.
I have also derived great and marked advantage from hot fomentations to
the epigastric region of spirits of camphor and laudanum, in the propor-
tion of three parts of the former to one of the latter. It is important that
the liquid should be as warm as the patient can well bear,"*^ and the cloths
should be frequently renewed. A strong infusion of hops, with or without
laudanum, applied in the same way, will also generally answer an admira-
ble purpose. If these remedies fail, I resort to the mustard plaster, made
wholly of mustard and warm water or vinegar, without any admixture of
flour or corn meal; to be kept on until considerable redness of the skin is
manifest. This is a prompt, and generally a powerful remedy. Simulta-
neously with these means, I almost invariably direct frictions to the lower
extremities (if they be cold and pallid as they usually are) with warm dry
flannel, or warm brandy, with a little mustard or cayenne pepper mixed in
it. These should be perseveringly continued, until a glow is produced, if

* The physician cannot be too particular in his directions as to the mode of applying
fomentations. I am perfectly satisfied, from careful inquiry and observation, that these
and many similar remedies, often fail of the desired effect, and even do harm, because
they are unskilfully or carelessly employed. This remark may be extended particularly
to the use of injections and external frictions.

309

Lindsly’s Remarks on Cholera Infantum*

possible, on the surface, and will be found to aid materially the object in
view. Indeed, this last means I almost invariably prescribe once or twice
every day, throughout the progress of the disease, so long as the state of
the cutaneous circulation indicates its propriety, and I am very confident
that if judiciously and regularly employed, it will do very much towards
equalizing the circulation, abstracting the blood from the internal organs,
and diffusing it equally over the whole system — a result of vast importance
in accomplishing a cure.

Whether these remedies are efficient or not in checking the vomiting,
(though they very seldom fail,) I do not wait to try other means, but pro-
ceed without further delay to the* administration of what is undoubtedly
our most important therapeutic agent in this disease, viz.

Calomel. — This efficient remedy is recommended to us, not only by its
powerful influence over the hepatic system, in relieving its engorgement and
bringing on a healthy flow of bile — but because, on account of its diminu-
tive bulk and freedom from disagreeable taste and smell, it is much more
easily administered to children, and more readily retained by the disordered
stomach, than any other purgative whatever. These latter considerations
alone, are sufficient to entitle it to a decided preference. But when in addi-
tion, it has been proved by the concurrent testimony of our most skilful and
enlightened physicians, for nearly half a century, to be so peculiarly adapted
to the state of the system as to deserve almost the title of specific, the most
skeptical or timorous can hardly hesitate to administer it.

In the language of Dr. Edward Miller of New York — one of the most
skilful, learned and brilliant physicians this country has ever produced, and
to whom I believe, we are chiefly indebted for the introduction of this remedy
in cholera infantum — as the stomach and intestines are found to require
evacuation, the most safe and unequivocal means, it is conceived, may be found
in the use of calomel, accommodated in its dose to the age of the patient,
and to other circumstances. As long as mere evacuation can be requisite
or admissible, this medicine uncombined will prove efficacious, gentle and
safe.”

^ Mild cases of cholera, and particularly in the forming stage, where there is merely
diarrhoea, with little or no vomiting, can occasionally be broken up at once, either by tho
oleaginous mixture, or what I prefer, the aromatic syrup of rhubarb and tincture of opium
in very minute doses. To a child fifteen months old, I generally order thirty drops of
the syrup, and one drop of laudanum every three or four hours, to be continued till the
discharges become less frequent and more natural. The practice of checking the evacu.
ations at once, by full doses of laudanum and astringents, without purgation, cannot be
too severely reprobated as not only injurious, but highly dangerous. The repose and
relief afforded to the bowels, are but temporary and delusive. While there is great
reason to apprehend a translation of the disease to the brain, producing serious inflam^
mation of that organ, and perhaps terminating in hydrocephalus.

310 Lindsly’s Remarks on Cholera Infantum,

Great care should be taken that the dose be accurately adapted to the symp-
toms of the disease, and the age of the child. To a patient, a year old, it
will seldom be proper to give more than a fourth or a third of a grain every
hour; the medicine to be continued, till a decided change takes place in the
appearance of the evacuations, which will be manifested by their becoming
more copious, less frequent and of a dark brown or green colour. As soon
as these alterations have been effected, we shall generally fiqd the little suf-
ferer much relieved — his skin becoming soft and moist — his eye brighter and
his countenance indicating freedom from pain and anxiety. It may still how-
ever be necessary to continue the calomel, but the interval may be extended
to two or three hours; if the symptoms seem to demand it, the same course
may be pursued on the second and even on the third day, though it is seldom
necessary to carry it so far.

The mode of administering the calomel is a matter of considerable conse-
quence. The common method, combining it with very finely powdered
white sugar and throwing it dry into the mouth, answers very well in some
cases. I have often remarked, however, that where there is considerable fever,
and the mouth in consequence parched and dry, the child has great difficulty
in swallowing it, as there is no saliva to dissolve it, and retching and no little
irritation are necessarily caused. In such cases — and indeed generally — I
prefer mixing the calomel in a few drops of the syrup of rhubarb. This,
when well prepared, is almost always agreeable to the child, and I am satis-
fied that it exerts a favourable influence on the action of the medicine,
diminishing or rather removing entirely its tendency to gripe and making
it more thorough and speedy in its operation.

Rleeding, Bleeding is seldom required in this complaint, and when
resorted to, should be practised with circumspection and in moderation; but
still there are cases, where the fever is high, the irritability of the stomach,
great, or a decided determination of blood to the brain, in which the applica-
tion of leeches to the abdomen or the head would be eminently useful.

Opiate Injections. Some authors recommend the administration of in-
jections of starch and laudanum in a very early stage of the disease, even
before the calomel has ceased to operate; a practice I could never bring my-
self to imitate, being persuaded that it must be injurious if adopted before the
engorgement of the liver and intestines is relieved. After this has been
accomplished and the system free from fever, I have always found them
useful, when skilfully given and the laudanum in appropriate quantity — ■
particularly at night, in order to keep the child quiet and afford him some
undisturbed sleep.

Warm Bath. The warm bath is unquestionably a remedy of considerable
power in cholera infantum, when judiciously directed and skilfully adminis-
tered; and yet I am persuaded from a want of proper care, it as often does
harm as good. Careful consideration should be given by the practitioner that

Lindsly’s FemarJcs on Cholera Infantum.

311

the situation of the patient demands it and very particular directions to the
attendants as to the best' mode of application, and then when followed
by stimulating frictions we will always find it useful — softening the skin,
unloading the engorged viscera and equalising the circulation. It may be
employed in almost any stage of the disease, if the strength be not too much
exhausted.

Blisters. Blisters to the abdomen, thighs, calves of the leg, &c., to relieve
nausea and to act derivatively, are rather favourite remedies with many physi-
cians. I seldom prescribe them for children — because, although means of
decided efficacy, they so often (in spite of the utmost care) become trouble-
some and occasionally dangerous from excessive irritation — and because, we
have a very efficient substitute in the various kinds of stimulating frictions,
syrup of rhubarb, sweet spirits of nitre, &c.

After some of the more violent symptoms have been subdued or abated,
and the evacuations rendered more natural by the foregoing treatment — and
which amendment usually takes place in from one to three days— there will
in a great many cases still remain indications of disordered action, as occa-
sional nausea and vomiting, more or less diarrhrea, fever, <fec., &c. This
state of the system requires great caution on the part of the medical attend-
ant, that he adapt his remedies to the precise situation of his patient, calomel
is no longer necessary; opium and astringents would do harm. I have here
for two or three years past, w'ilh very great, advantage, directed a combina-
tion of the aromatic syrup of rhubarb, and sweet spirits of nitre, according
to the annexed formula. B. syrup, rhei. aromat. spt. sether. nitras. aa
3ij; sacch. alb. mucil. g. arabic. ^ij; M., of which a teaspoonful every
hour or two will form a dose. If there is no fever, I generally add a small
quantity of paregoric, and if there be indications of acidity in the primae vise
a little prepared chalk. This simple prescription, continued if necessary for
two or three days, will in a great many cases, with the symptoms supposed,
afford entire relief and effect a speedy cure. The rhubarb being slightly
astringent and the nitre diaphoretic, form precisely the compound we want.
Whereas if we should prescribe the more powerful astringents combined
with laudanum, we might arrest the diarrhoea more rapidly, but in nine cases
out of ten, w^e should thereby bring on fever with probably irritation, per-
haps inflammation, of the brain^ — or else, the diarrhoea would soon return
w'ith increased violence and be more difficult than ever to control.

Sugar of Lead and Dover's powder. Where the diarrhoea proves obsti-
nate— not yielding to the above prescription and especially where it assumes
a chronic form, I do not believe there is a more efficient remedy in the whole
Materia Medica, than sugar of lead and Dover’s powder in doses carefully
proportioned to the age and condition of the patient. If there is much
fever or irritability of the stomach, neither would of course be proper. I
give this combination in those cases where the more powerful astringents as

312 Lindsly’s Remarks on Cholera Infantum.

kino, catechu, &c., are usually administered, and after a very careful compara-
tive estimate of the powers of the two classes of articles, and feel very
confident that in a vast majority of instances, where any thing of the kind
is proper, that the lead and Dover’s powder will act more kindly and effi-
ciently than any thing else. The dose should be very small and its effects
carefully watched, and the apothecary should be particular to mix the ingre-
dients thoroughly and divide them accurately. For a child eighteen months
I usually prescribe the following formula: R. sup. acet. plumb, gr. iv; pulv.
Dover, gr. i. Ft. pulv. No xij; one of which may be given every hour, or
every second or third hour, according to the urgency of the symptoms and
the effects of the medicine. My objection to kino and catechu is, that they
almost invariably produce straining and tenesmus, diminishing the quantity
of the evacuations, but not their number. They frequently act beneficially
in the diarrhoea of adults, but in that of children, I am satisfied they should
seldom if ever be used.

In the treatment of cholera infantum, I place my chief reliance on the
above remedies, variously modified and combined to suit the endless varie-
ties of constitution and symptoms. 'I’here are, however, various useful ad-
juvants in the management of bad cases which should not be overlooked.
Among these may be enumerated, the chalk julep — gum arabic water-flax-
seed tea — infusion of slippery elm bark — lime water — balsam of copaiva —
spirits of turpentine — charcoal mixed in mucilage of gum arabic, <fec., <fec.
Some of these articles will aid much in effecting a cure. When the stools
are slimy and the mucous tissue of the bowels much disordered, I have
derived great advantage from the spirits of turpentine, in doses of five to
fifteen drops several times a day. The balsam of copaiva will answer the
same indications very well. Mucilaginous drinks should always be at hand
for the child when thirsty. Gum arabic, and slippery elm bark make as
good as any.

In the chronic form of the disease, where the discharges seem to be kept
up by habit or mere debility, tonics will be highly useful. A great variety
have been recommended and all of them are probably beneficial. I seldom
employ any but quinine and the chalybeate preparations. These are rea-
dily taken and answer every indication. The quinine may be given in
powder or solution, the minuteness of the dose being a great recommenda-
tion. In prescribing the preparations of iron, I use either the mistur. ferri
compos., or the following formula of Dr. Chapman. R. sal. martis gr. ij;
acid, sulphur, gtt. x; sach. alb. ^i; aq. font, ^i; of which a dose is one
drachm, repeated pro re nata.

Flatulency is often a very troublesome symptom, when the disease has
continued a long time. Most of the ordinary aromatics and carminatives
will give some relief, though I prefer the anise seed tea, or small quantities
of the volatile alkali in cinnamon water. This latter prescription has sel-
dom failed in my hands.

Lindsly’s RemarJes on Cholera Infantum. 313

One great difficulty we have to contend with in the treatment of the sequelae
of cholera infantum, is the constant tendency of the patient to relapse. He
may be relieved or cured of one attack, and in two or three weeks, perhaps,
he will be seized!again; and this may occur time after time, till the patience
of the friends, and perhaps of the physician, is completely exhausted; they
despair of final success and allow the disease to take its course, which con-
sequently soon terminates in death. This is a very erroneous view of the
proper power of remedial treatment, and I have no doubt, that many a life
has been sacrificed to it, which might readily have been saved, by again
recurring to the same or similar remedies, which were successful in the first
instance. As soon as a relapse takes place, not an hour should be lost, but
immediate means adopted to check and control it. As a general rule, if
the healthy interval has been short, calomel will not be needed. After giv-
ing a single dose of castor oil, syrup of rhubarb or magnesia, we may resort
to some of the remedies recommended in the former part of this article.
And this course should be persevered in, as long as the relapses recur, or
the complaint continues. I have repeatedly seen children attacked from six
to ten times in one season, and yet carried safely through them all, while there
is every reason to suppose, that, if the parents had yielded to the too pre-
valent notion that medicine was of no avail after the first or second attack,
they would soon have paid the forfeit of so mistaken a notion. We should,
therefore, never intermit our efforts as long as life continues — and there is
no disease, perhaps, in which perseverance and patience are so often re-
W'arded by success as this. Great care should of course be taken to adapt
our remedies to the debilitated and altered condition of our little patients.

Diet, If the child has not been weaned, and the mother has an abund-
ance of wholesome milk, little else is needed, or should be allowed in the
way of food, during the whole progress of the disease. The mucilaginous
drinks before referred to may be given to quench thirst and amuse the
patient, but beyond these, the less they take as a generul rule the better.
Where the child is weaned, however, or the supply of milk is scanty, or
its quality impaired, it will be necessary to resort to other articles of food —
which should always be prescribed by the physician himself, and not left
to the whims and caprices of the nurse, as unless this part of our duty is
carefully and faithfully attended to, every thing else will be of little avail.
The farinaceous articles, as arrow-root, sago, tapioca, barley, rice, &c. with
milk and sweetened with loaf sugar, should be directed. These, with or
without a little spice, will afford a sufficient variety, and can be made very
palatable to the fickle appetite of the little patient. Occasionally, in cases
of long standing, benefit has been derived from allowing a small piece of
ham or salt fish.

Great care should be taken of the child’s dress, that it be made of proper
materials and that it be not capriciously changed from thick to thinner arti-
cles so as to incur the risk of checking perspiration and causing a chill.

No. XLVIIl. — August, 1839. 27

314 Annan’s Baltimore Alms- Home Ho spxtal Report,

A flannel shirt, made to fit pretty tightly and to cover the whole abdomen,
should be worn for the first two years without intermission. If it be op-
pressively warm, it may be of a light kind for summer. JFhis, with long
woollen or worsted stockings, will constitute the most important article of
dress, and will guard pretty efifectuallj^ against sudden vicissitudes of tem-
perature, whatever else may be worn.

Article VI. Report of Cases Treated in the Baltimore Almshouse Hos-
pital. By Samuel Annan, M. D., Senior Physician to the Institution.

Dysentery. This disease did not entirely disappear until the beginning
of winter. Since that time no new cases have been presented; and the
obstinate diarrhoea which succeeded the acute attack, in a few instances,
has either been cured, or the cases have terminated fatally. The plan of
treatment mentioned in my former report, was attended by the happiest
results, in all the cases which were seen early. The relief from the most
distressing symptoms was immediate; and a perfect cure speedily fol-
lowed. My subsequent experience, and the condition of the mucous mem-
brane of the colon, as seen in several cases, on examination after death, have
brought me to the conclusion, that this mode of treatment, which answers
so admirably in the early stages, must be materially modified, or totally
changed, in order to suit the more advanced periods of this painful and dan-
gerous disease.

Dysentery is known to be an inflammation of the colon and rectum,
occasionally extending a short distance into the small intestines. This
inflammation, sooner or later, according to its greater or less degree of
intensity, produces softening and ulceration of the mucous membrane, its
primary seat. Sphacelus, denoted by blackness or lividity, and softness of
this membrane, the muscular coat occasionally partaking of this softness, is
a less frequent occurrence. Where the disease has existed for any length of
time, extensive ulceration, with softening of those portions of the mucous
membrane, not destroyed by the ulcers, is the common appearance. TJae
extent to which this ulceration sometimes proceeds, before life is destroyed,
is very surprising. I have seen the greatest part of the rectum and colon,
almost one continued ulcer, portions of the lining membrane in a state of
red fungous elevation, being interposed here and there; by which the ulce-
rated spaces were separated from each other.

From this statement of the morbid appearances, it is manifest, that when
the disease has advanced so far, that disorganization of the mucous mem-
brane has taken place, it is worse than folly to attempt to cure it by the
administration of even the mildest cathartics. If softening and ulceration

Annan’s Baltimore Alms-House Hospital Report, 315

exist, the period has gone by, at which we might expect to afford relief, by
gently stimulating the diseased membrane, in order to make it deplete itself,
by augmenting its secretion, and thus remove the engorgement from its
distended vessels. The vitality of these engorged vessels has, by this time,
been impaired to that degree, that they cannot be excited to a secretory
effort, the effect of which would be, a tendency towards a restoration to
healthful action. Stimulation wdll now only increase the morbid action,
and hasten, or extend the ulceration. Calomel and opium, and large doses
of castor oil, are therefore inadmissible. Instead of allaying the irritation,
diminishing the pain, and causing the patient to feel more comfortable;
after the effect of the opium goes off, the symptoms will be aggravated;
the soreness and tenderness of the abdomen, will be increased; the tormina
and tenesmus rendered more harassing. This is the state of things, which
has brought laxatives into disrepute. Their reiterated administration has
only served to make the patient worse, and it has in consequence been
inferred, that they are always injurious.

It is impossible to specify any particular time, at which the changes of
the mucous membrane, of which I have spoken, take place. So much
depends upon the violence of the disease, and the strength of the patient to
resist. This general rule, however, may be laid down, viz, that the longer
the time which has elapsed from the commencement of the attack, the
greater is the risk from the exhibition of large doses of purgative medicine,
and the greater the necessity for other modes of depletion, proportioned to
the strength of the patient. It should also be rememberedj that the case
may not be seen, until the strength has been so much exhausted, that
depletion of every kind, may be altogether inapplicable. Such cases will
generally have a fatal termination. In a few instances, under careful ma-
nagement, they nevertheless recover. An intractable diarrhoea continues
until the ulcers cicatrize, and the tender parts regain their healthful condition.

In the treatment of dysentery of several days standing; where the attack
has been violent from the beginning, and the sufferings of the patient are
great, blood letting, both general and local, is plainly indicated. We have
a dangerous inflammation to manage, which is threatening disorganization
of an important part of the organism; and our most powerful remedies
should be employed, with an energy proportioned to the strength of the
patient, and the character of the disease. Blood should be abstracted copi-
ously from the arm, and cups or leeches, applied along the course of the
colon, in the right and left iliac and lumbar regions, if it is thought the
patient cannot well bear a repetition of the general bleeding. In robust per-
sons local bleeding does little or no good, prior to the effectual subjugation
of the vigorous action of the heart, by taking from the whole system.
Where the patient will bear the loss of from twenty-four to thirty-tw'O
ounces of blood from the arm, local bleeding is not immediately necessary.

316 Annan’s Baltimore Jllms-House Hospital Report,

and may be reserved for a subsequent period. The next inquiry is, what
should follow the bleeding? If too long a time has not elapsed, I am satis-
fied, that a full dose of calomel and opium, followed by castor oil and Do-
ver’s powder, as formerly recommended, is preferable to all other remedies.
But it will be asked, what is too long a time? I can only reply, that I have
thus treated persons, who had been as ill as they apparently could well be,
for seven or eight days, and nothing done during all this time, with the
effect of immediate relief, and final recovery. In some cases, one bleeding
was all that was required; in others, two were requisite, the second being
prescribed, one, two, or three days after the first. Occasionally cups were
employed after the first bleeding. As we cannot specify the precise period
when free purging becomes inadmissible, I apprehend we may come pretty
near the true slate of the case, by attending to the following circumstances.

If the patient has been ill during two or three weeks and is greatly
reduced, it is plain enough, that the time for active treatment has passed. If
on the other hand, he has been ill but a few days, and still retains consi-
derable strength, bleeding and purging should be tried, and if relief of some
permanency is procured, we may be encouraged to persevere in the purging
plan. But if there is a speedy and perpetual recurrence of the tormina and
tenesmus, as soon as the effect of the opium disappears, and along with this,
there is an increase of the soreness and tenderness of the abdomen, along
the course of the colon, it is obvious our remedies are doing harm, and a
different and milder course must be adopted. In this state of things, the
proper remedies are emollient and anodyne injections, fomentations and
blisters to the abdomen, an occasional warm bath, at the temperature of
100°, Dover’s powder to allay irritation and determine to the surface, with
small doses of castor oil combined with laudanum, to carry off the acrid
contents of the bowels. The best effects not unfrequently follow the admi-
nistration of one or two teaspoonfuls of castor oil, with twenty drops of
laudanum, night and morning. If the tenesmus should now and then become
more troublesome under this treatment, an ounce of the oil, with fifty drops
of laudanum, will give ease, and the small doses may then be continued.
Even where there was ulceration, as far as I could judge, my patients
always felt relieved by two or three pretty free evacuations, by castor oil.
It is so much less irritating than the acrid secretions, that it is by comparison
soothing and emollient.. When the disease has become decidedly chronic,
we must have recourse to the remedies of which I spoke in my former paper.

Pleurisy. Several cases of acute pleurisy have been admitted, through
the course of the winter; They were all treated on a plan somewhat dif-
ferent from that usually practised,, and with success, although the disease
had existed, in every instance, from two or three days, to two weeks. To
bleed with an unsparing hand from a large orifice, and in the manner best

Annan’s Baltimore Alms-Home Hospital Report, 317

calculated to make the speediest impression on the system, is the invariable
recommendation of the best writers. If one bleeding fails to afford very
decided relief, we are advised to repeat it in a few hours, and to resort to
the operation again, at more or less distant intervals, according to the ur-
gency of the symptoms, and the capability of our patient to bear further loss
of blood. The general rule, adopted by some practitioners, as to the limits
to which sanguineous depletion should be carried, is deduced from the
strength of the patient, and the relief of the pain and irritability of taking in
a full inspiration. In conjunction with the general bleedings, cups and
leeches are to be applied to the affected side. This course of blood-letting,
combined with purgatives, diaphoretics, diuretics, sedatives and mercury,
occupies several days, and when the patient is thought to be in a poper state
of preparation, the fever being sufficiently reduced, or in other words,
brought down to the blistering point, blisters are directed to be applied over
the seat of pain.

The plan which I have followed during a number of years, and in no
instance has it failed of effecting a speedy cure, differs from the foregoing in
the following particulars, viz: immediately after a free bleeding from the
arm, a blister is applied to the side, and half a grain, or if that nauseates too
much, a quarter of a grain of tartrate of antimony is given every two hours.
Fifteen or twenty grains of calomel, combined with five or six of pulvis
antimonialis, are given at bed time; and if the bowels are not acted upon
two or three times, pretty freely, against morning, a moderate dose of Ep-
som salts, or castor oil is exhibited. After the purgatives have operated,
recourse is again had to the antimony. The second night at bed time, ten
or twelve grains of Dover’s powder are given and repeated every night, and
in the morning the antimony is resumed. In three, or four, or five days,
the antimony may be discontinued, or the dose very much diminished. In
very few cases have 1 found it necessary to repeat the bleeding from the
arm, and cups and leeches have not been employed at all, neither is any
other medicine for the most part required; inasmuch as the antimony gene-
rally keeps the bowels sufficiently open.

The objection which I suppose lies againt the practice of postponing the
application of the blister until the patient shall have been repeatedly bled^
cupped and leeched, is, that although the first bleeding, by abstracting a cer-
tain portion of the circulating fluid, and reducing the action of the heart
relieves the congestion of the affected vessels, and diminishes or entirely
removes the pain, as the blood-vessels soon fill up again, and the heart
recovers in a great degree its former power and force of action, lessened some-
what, it is true, by the blood being of a less stimulating quality from the
increased quantity of serum it contains, the vessels of the inflamed pleura
are distended afresh, and the pain, and fever which arise from it are renewed,
of course accompanied by the dyspnoea. In this way the symptoms dis*»

27*

318 Annan’s Baltimore Alms-House Hospital Report.

appear and reappear alternately, in greater or less degree, until the patient
is so much reduced that there is not force enough in the heart’s action to
cause a return of the distension of the inflamed vessels. When bleeding is
carried to this extent, the disease is subdued, and a blister is of compara-
tively little service. The patient will now get well under mild treatment,
as fast as he can recover from the debility produced by the remedies.

But suppose the blister is applied immediately after the first bleeding,
before the excitement has time to return with its former force, we have all
the benefits of counter-irritation from this remedy; a new inflammation has
been set up on the surface, directly opposite the principal seat of the origi-
nal disease; arterial and nervous action are determined towards this part;
and, as a necessary consequence, if the doctrine of counter-irritation is
good for any thing, there is diminished action inside. The new disease
draws off the morbid action from the old one, and the symptoms of pleurisy
do not re-appear. Or it may be said, that the external stimulation rouses
the latent powers of the vessels of the inflamed pleura, and they do not
suffer themselves to be again dilated so as to cause pain. Whatever theory
of counter-irritation we may adopt, there is no doubt of the fact, that the
disease of the skin produced by a blister, does diminish internal inflamma-
tion. This is universally admitted; and the only question now at issue, is
as to the time of applying it.

The objection brought against the early application is, that there is great
danger that the irritation of the blister itself may increase the fever, to a
degree which will more than counterbalance the good that might otherwise
result from its remedial virtues. That the increase of the general excite-
ment may augment, in place of lessening the local disease. This is a ques-
tion of fact, which can only be settled by observation. I can only say that
I have not found this to happen. On the contrary, the reverse has con-
stantly occurred. The pain, the dyspnoea, the cough and the fever have
all been diminished, and the patient has invariably expressed himself as
being better. This, indeed, is what we might expect from sound physiolo-
gical and pathological views of the subject. For, although it must be
admitted that blisters are irritants, and if applied in a healthful condition of
the system, would cause more or less fever; it is, notwithstanding, a fact,
that where a much more intense irritation exists internally, as in the cases
of pleurisy and peritonitis, the he^t, through the medium of the nervous
system, does not feel the irritation of the skin; but this inflammation, when
compared with the more severe pleuritic affections, is as nothing; and in
proportion as it relieves the symptoms of the diseased pleura, will it act as
an anodyne, and allay morbid excitement; or, in other words, diminish
fever. It is on this principle we explain the fact, that our patients will
sometimes sleep during the whole time a blister is drawing; which, in many
instances, is the first sleep they have had during several days and nights.

Annan’s Baltimore Alms-House Hospital Report* 319

Case. Laceration of Urethra— Abscess of Leg — -Phlebitis. — J. A ,

aelat. 30, full and muscular, was admitted into the Alms-House Hos-
pital, November 19th, 1838, in consequence of injury sustained by a fall,
from no great height; but having come down astride of a board, the perineum
received the whole force of his weight, and being a large heavy man, there
was considerable contusion. On the afternoon of the same day, he was
admitted, and I found him complaining of great pain in the perineum, with
difficulty of passing his urine, which came away in small quantity, accom-
panied by a good deal of blood. The bladder could be plainly felt above
the pubes, and was painful on pressure. There was no external wound,
but the scrotum and perineum were black from ecchymosis. I attempted to
introduce the catheter, intending to leave one of gum elastic in the bladder;
being apprehensive from the injury done to the urethra, that there would be
infiltration of urine into the scrotum and perineum. The instrument could
not be passed farther than the membranous portion of the urethra, although
different sizes were employed. Blood flowed freely from the penis during
the trials; and what was much more gratifying, urine came away in suffi-
cient quantity to relieve the bladder. Fomentations were applied to the
perineum; the bowels opened with a laxative; and rest enjoined. I fully
expected infiltration of urine, with a return of the retention; and that I
should have to make free incisions into the scrotum and perineum, to allow
the escape of the urine, and prevent extensive sloughing; and also to open
a passage into the bladder, along the course of the urethra, from the peri-
neum. Contrary to my expectations, there was no farther accumulation of
urine in the bladder; neither was there any infiltration. The urine passed
off by the urethra, as soon as the bladder was moderately full; some blood
being also voided during several days; and each micturition being attended
by excruciating pain. The pain, however, in a few days moderated, and
then disappeared altogether. The discharge of blood ceased, the urine
flowed freelys and I thought my patient was in a fair way to recover. The
ecchymosis of the perineum and scrotum continued longer. I now came
to the conclusion, that the urethra had not been lacerated, but simply con-
tused; as I did not recollect any case of laceration of that tube, unaccom-
panied by infiltration of urine into the surrounding cellular structure.

About a week after the reception of the injury, a new symptom presented
itself, viz: swelling and pain of the calf of the right leg; and in about
another week, the left ankle also became painful and tumid. The swelling
extended in the course of a few days, to the feet, which became oedematous
and greatly distended. The right leg, as far up as the knee, also became
oedematous. The pain was excruciating; and the skin, at first, was slightly
reddened, especially that of the left ankle. Various applications were made
to the inflamed parts. /Emollient poultices were first tried; but as they
gave no relief, they were soon exchanged for cooling lotions. White wash
and spirit wash were applied, by means of cloths kept constantly wet with
them. The former is the liquor phtmbi subacetatis solutus, of Wood and
Bache’s Dispensatory. The latter consisted simply of water, and a small
portion of proof spirit, to make the evaporation more rapid, 'i’hese miti-
gated the pain but little, and the parts were then enveloped with cloths kept
constantly wet with water as warm as could be borne. This gave more
relief than any other application. His system had received such a shock,
and the pulse was so feeble, that I did not think blood-letting admissible.
He was, however, purged moderately, and low diet was prescribed.

No cause could be assigned for the inflammatory affection of the two

320 Annan^s Baltimore Jllms-House Hospital Report,

limbs. He did not complain of any injury having been done to them, when
he came into the hospital. I was therefore disposed to regard the affection
as an inflammation of the cellular and ligamentous tissues, arising, in a bad
condition of the organism, from the urethral irritation. The swelling of the
limbs continued to increase, the skin becoming pale from the effusion of
serum in the sub*cutaneous cellular tissue; and he began to complain of
pain extending up the thigh, along the course of the great blood-vessels,
whicli was greatly aggravated on pressure; particularly at the upper part of
<he thigh, just below Poupari’s ligament. The superficial veins of the thigh
were now somewhat distended. There was no general tumefaction of the
thigli* He gradually became more and more debilitated; the stomach
became irritable; and he finally sunk on the 24th of December.

Autopsy 24 hours after death. A large abscess containing bloody pus,
was found underneath the gastrocnemii muscles of the right leg, situated
between them and the deeper muscles, and occupying two thirds of the
leg, midway between the ankle and knee joints. 'J’he parts of the muscles
adjacent to the abscess, were completely disorganised, being reduced to a
soft pulpy mass. The posterior tibial, the popliteal, and the superficial
femoral veins, and their continuation up to the junction of the common iliac
with the vena cava, were lined with a thick, dense, false membrane, and
filled with yellow pus. All the veins of the thigh were filled with pus in
the same manner. None of these veins in which pus was seen, con-
tained blood. The anterior tibial vein was not so much diseased as the
others. At the termination of the common iliac vein, in the vena cava, a
considerable quantity of a more solid matter was observed, apparently con-
sisting of a mixture of lymph and pus, which blocked up the entrance
into the vena cava, and probably prevented the pus from passing on
towards the heart. There were redness and thickening of the ligamentous
tissues around the left ankle, and some pus was found in the joint. A small
abscess had also formed at the root of the great toe of the right foot. The
bladder having been taken out with the penis, and the urethra slit up, a
cavity about the size of a small walnut was seen at the beginning of the
membranous portion of this tube, where it joins the bulb, into which both
ends opened. The external end terminated abruptly, with a considerable
depression, as if the tube had been cut ofi', then joined to the sac, and badly
fitted. The end next the bladder was united to the sac by a smooth, level
surface. The interior of the sac was lined by what seemed to be a perfect
mucous membrane. The viscera were normal.*

Remarks, The calf of the right leg must have been severely contused
by the fall; although he made no complaint of it. The pain about the
region of the bladder was so excruciating, that the injury of the leg was not
felt. The bloody pus contained in the abscess, proves that there was a con-
tusion. The left ankle must also have been sprained. There was nothing
peculiar about the phlebitis. It pursued its usual course, viz. effusion of
lymph, formation of false membrane, and secretion of pus. The small

[* This case is an interesting one. It affords a marked example of traumatic phlebitis
terminating in purulent depots, or what is considered by some writers, secondary abscesses.
Some cases of a similar character are recorded by Dr. Watson, in his valuable memoir
cm Secondary Abscesses^ ih the^Na. of this Journal for November, 1837. — ed.]

321

Annan’s Baltimore Mns-House Hospital Beporf.

amount of tumefaction of the thigh, might at first view cause surprise; but
when we reflect, that the passage of the blood through the veins appears to
be completely interrupted in phlebitis, these vessels containing nothing but
false membrane and pus; and that the arteries are but little dilatable, under
the strongest action of the heart, and are diminished, in diameter, in states of
debility, in proportion as the weakness is greater or less; our surprise will
cease. It is the dilatation of the veins, which are susceptible of a great
degree of distension, which is the principal cause of swelling of parts, ante-
cedent to effusion taking place. In phlebitis, the veins are entirely relieved
from® the force of the heart’s contraction; therefore they cannot be subjected
to congestion of blood; and if effusion does not take place into the sur-
rounding tissues, there will be little swelling. With so complete an inter-
ception of the venous circulation, one might expect to find gangrene and
sphacelus. There was not however either of these conditions observable
in the thigh. The disorganization around the abscess, was manifestly the
consequence of the inflammation arising from the contusion. Although
this patient was too much debilitated to allow of bloodletting from the arm,
if leeches had been at hand, he might perhaps have been benefitted by their
application along the course of the inflamed vein; or to the leg, on the first
appearance of the swelling. Still it is doubtful, whether they would have
prevented suppuration.

The most remarkable part of this case is the laceration of the urethra,
without infiltration of urine as the consequence. The urethra was plainly
torn across, and entirely divided at the arch of the pubes; probably by being
driven against the arch; and nevertheless no urine passed into the surround-
ing cellular tissue. As far as I remember, this is an unprecedented occur-
rence. The sac which was seen, must have been formed by an effusion of
blood, which dilated the parts, and caused a consolidation of the cellular
tissue; thus forming a cavity filled with blood. When this blood coagulated,
its fibrine may have partially separated, and adhered to the surface of the
cavity, and thus cemented the plates of the cellular tissue together so as to
prevent the escape of the urine. Or previous to coagulation, the blood may
have filled the interstices of the cellular tissue, so that when coagulation took
place, the urine could not find a passage. However we may explain it, the
fact is unquestionable; and the wonderful resources of the system, are well
exemplified, in the reparation of the damages.

Dysmtery — Chronic Arachnitis — Chronic Gastritis — Malformation of
the Genital Organs, G. W. aetat. 32, an idiot, was admitted into the
Alms House on the 3d of .Tuly; and shortly afterwards attacked by dysentery,
which became chronic; and he gradually wasted away under a diarrhoea;
which was not however very severe, but could not be entirel)’ checked, and
was occasionally aggravated without apparent cause. He complained of
pain and soreness of the lower part of the abdomen, for which he was cupped
and blistered, with partial and temporary relief. He died December 18lh
1838.

322 Annan’s Baltimore Mms-House Hospital Report,

Autopsy 36 hours after death. Brain. There was considerable thicken-
ing and consolidation of the arachnoid membrane, covering both hemispheres
of the cerebrum. The entire membrane was pulled oflf without laceration,
the processes of pia mater, which pass between the convolutions, coming
out readily with it. After washing in clean water, it was held up to the
light, and exhibited the usual transparency; but was firm and unyield-
ing, and considerable force was required to tear it into fragments. It did
not appear to be changed from the normal condition, on the base of the
cerebrum; but on the inferior part of the cerebellum where it passes from
the medulla oblongata, it was thickened; and underneath this part there was
a small quantity of sero-gelatinous effusion. 'I'he cortical part of the cere-
brum did not present any thing remarkable. The convolutions were of the
usual depth and shape. Mr. Reynolds, one of the students of the house,
was disposed to think the convolutions deeper than is common. There was
some congestion of the medullary matter. Red points were numerous when
it was sliced; and the veins of the lateral ventricles, on the surfaces of the
thalami, and in the posterior and inferior horns of the ventricles, were greatly
distended with blood. The plexus choroides was not much congested.
The septum lucidum, the fornix, and the surfaces of the thalami, were
slightly softened. No morbid change was observed in the cerebellum.

Thorax. The right lung was healthy. Two thirds of the upper lobe
of the left lung, adjacent to its junction with the lower lobe, were in a state
of splenization having become as solid as a piece of liver; and presented a
smo-oth red surface, when cut into, without the smallest appearance of
granulation. There were no adhesions of the pleurae, on either side.

Abdomen. The stomach, over the whole interior, was of the colour of
slate, perhaps not quite so dark a blue; and on stretching it, red vessels
were observed underneath the blue surface, forming a red ground. The
mucous coat was softened, and when scraped, both the blue and the red
colours came off, leaving the whitish muscular coat bare. There was no
ulceration of either the small or large intestines. The lower part of the
ilium for about ten or twelve inches in extent, was of a dark mahogany
colour; and the mucous coat could be scraped off in the form of a red pulp.
Spots of red softening were seen in the caput coecum and ascending colon;
and in the sigmoid flexure and upper part of the rectum, there were numerous
small tumours of a dark blue colour, the longest one-third of an inch in
diameter, formed in the mucous coat, and resembling punctated melanosis.
The liver was normal as to size, but was of a dark purple colour, both exter-
nally and internally; the yellow medullary matter having entirely disappeared.

Genitals. These organs presenled-an extraordinary malformation. Both
of the testicles, of the normal size and feel, were contained in one tunica
vaginalis, viz, that of the right side. They lay with what is commonly
their anterior surfaces, directed towards each other; and were bound toge-
ther by three or four bands passing off from their serous surfaces. The
epidydimis of the right testicle looked towards the right thigh; that of the
left towards the left thigh. Two vasa deferentia were given off, one from
each epididymis, and were traced into the pelvis, through the external ring,
down to the bladder. 'J'hese tubes were normal. In addition to them,
there was a third tube, of much larger size, along its entire course from the
testicles, being fully as large, or larger than the biggest goose quill, which
passes out from between the two testicles, communicating with the tubuli
seminiferi of both, as was proved by injecting these tubuli with quicksilver
through it, and by it containing serum from one end to the other, and ter-

Annan’s Baltimore Mms-House Hospital Report, 323

minated in the nrelhra of the apex of the prostate gland, viz, at the caput
gaUmaginis. About three or four inches from its termination it expanded,
so as to be more than an inch in circumference internally; but ^t again con-
tracted, so as to enter the urethra by a small opening. The two vasa defe-
rentia, when about entering the abdomen through the external ring, at-
tached themselves to the sides of this tube, and accompanied it to its
entrance into the urethra, and opened into it, in the substance of the prostate
gland. No vesiculse seminales, diverging from the base of the prostate,
were to be seen. This long tube appears to have been substituted for them.
The coats of this tube were apparently the same, as those of the seminal
vesicles, in other cases. After the entrance of the three ducts into the abdo-
men, they were nearly surrounded by the peritoneum; and also by a dense
cellular coating; all of w'hich formed a large cord, passing down into the
pelvis. The external and internal abdominal rings appeared to be united
into one, by the inner ring being drawn towards the tubercle of the pelvis.
The spermatic cord consequently passed straight into the abdomen, there
being no oblique canal. The ring was open, and there was a hernial sac,
separated from the testicles by a thin cellular partition. This partition
was covered on one side by the tunica vaginalis testis; and on the other by
the peritoneum. The sac contained a portion of the ilium, which was early
reduced, not having formed any attachments.

There was but one artery going down to the testicles; but it was about
twice the size of the spermatic artery in ordinary cases; and it arose from
the internal iliac, about an inch and a half, or two inches from the bifurcation
of the common iliac artery. On the left side, an artery of not much smaller
diameter, arose from the internal iliac, at the corresponding point; but instead
of going out of the abdomen, through the rings, it ran forwards and upwards
and terminated abruptly on the rectus abdominis muscle. The right sper-
matic vein originated from a large cluster of veins, in conjunction with the
left, which cluster lay between the vasa deferentia, at the top of the testicles.
The two veins continued together until they entered the abdomen, and
then separated. The vein of the right side took the usual course upon the
psoas muscle, and terminated in the vena cava. That of the left side was
carried across the pelvis by a curious bridge which remains to be described.
The fundus of the bladder did not pass forwards to the crest of the pubes,
by about two inches. Just at the top of the bladder, there was a duplica-
ture of the peritoneum, two and a half inches wide at the symphysis pubis,
which stretched from, one side of the pelvis to the other, and was attached
to the psoae muscles and brims of the pelvis on each side, thus forming a
complete bridge across the cavity. Along the upper edge of this fold of the
peritoneum, between the two layers, the left spermatic vein passed from the
right abdominal ring to the left side, ran upwards upon the psoas muscle, and
terminated in the splenic vein. The penis was of the largest size and well
formed. The opening of the external muscle of the left side, which forms
the external ring, was normal.

Remarks, It is an established fact in embryology, that the testicles, up
to the beginning of the seventh month of utero-gestation, are situated in the
abdomen below the kidneys, one on each side of the spinal column, and occupy
all the inner face of the ossa ilia. About the end of the eighth month they
pass through the external abdominal rings; and towards the termination of
the ninth month, are usually found in the scrotum. Now according to the

824 Annan’s Baltimore Alms-House Hospital Report,

Centripetal Theory of Development, of M. Serres, the very young embryo
consists of two halves, separated by aline of division, through the centre of the
spinal column, and by the coalescence of these two portions, the perfect foetus
is formed. Where the organs are double afterbirth, each lateral half forms its
own; and where they are single, as in the cases of the scrotum and penis,
the two lateral halves, which are developed apart from each other, unite
along the mesial line. These being admitted facts, the question arises,
whether in the case above narrated, the two testicles, in opposition to the
ordinary law of developements, were originally formed on the right side; or
did the left one, during the progress of embryotic existence, and subsequently
to the junction of the two lateral halves, pass over to the right side? If one
of the spermatic veins had got crossed over to the left side, I should be
inclined to adopt the first conjecture. This division of the blood-vessels, the
artery going off from the right, and one of the veins terminating on the left
side, makes it impossible to decide as to the original portion of the left testicle.
The junction of the left spermatic vein with the splenic vein is also uncom-
mon. The connection of the vasa deferentia, and likewise of a large central
tube, with the tubuli seminiferi is, I suspect, unprecedented.

There is nothing in this case, as far as the structural condition of the cortical
part of the brain is concerned, to favour the theory of M. Foville and Pinel
Grandchamp. They have conjectured, that the cortical substance is the seat
of intelligence, whilst the medullary is intended to preside over motion.
They think they have discovered, that in cases of imbecility, the convolu-
tions are small, and the cortical substance is reduced to a very thin layer.
Neither the one nor the other was observed in the above case. It may
nevertheless have been, that the functional disturbance produced by the
chronic arachnitis, was sufficient to have caused the imbecility of mind.

Hemiplegia — Dysentery — Mental Aberration. G. W., aetat. 50, an old
sailor, of intemperate habits, has been an inmate of the Alms House since
1832. When first admitted was affected with hemiplegia of the left side. In
walking his left leg was dragged along with difficulty; and was made to
describe part of a circle; and he had very imperfect use of his left arm.
His mind also was impaired, so that he was considered partially insane.
He was extremely irritable, cross, and snappish; and ready to strike with
the stick he used in walking, regardless of rank, any person who provoked
him. He appeared to know what he was doing, and to understand what
was said to him; but seemed to be incapable of self-control.

In the beginning of November he was attacked slightly with dysentery,
W'hich he suffered to run on without complaining, and it settled down into
an intractable diarrhcea. He now became so offensive, from inability to
restrain the discharges, that the attention of the head of the ward was attract-
ed, and his case mentioned. The account the patient gave of his situation,
was so confused that I could make nothing out of it; but the constant faecal
discharges in bed, showed plainly the nature of the disease. Various reme-
dies were prescribed; some of which he took, and others he refused. Two

- Annan’s Baltimore Alms-House Hospital Report. 325

or three times he seemed to be g^etting better; but he again relapsed to liis
former state; and he died on the 26lh of December, 1838.

Autopsy. Brain. After removing the top of the cranium, on attempting
to take off the dura mater, strong adhesions were found between the two
surfaces of the arachnoid membrane; not only along the central margin of
the right hemisphere, but also over the whole surface of the middle lobe of
the right side. In the efforts to get the dura mater off, the arachnoid came
away from the middle lobe, bringing with it the processes of pia mater from
between the convolutions, and also portions of the cortical substance of the
brain; which was found to consist of a soft pulpy matter, not changed in
colour. On examination the whole of the middle lobe of the right hemi-
sphere, with about half of the anterior and posterior lobes of the same side,
were likewise found to be of the consistence of a soft pulp; so that on trying
to lift a portion of it with the fingers, it tore asunder, showing it to be des-
titute of its usual adhesive properties. Both the medullary and cineritious
matter were in this condition. The great mass of the left hemisphere was
as firm and solid as when there is no disease of the brain, but the surfaces
of the corpus striatum and thalamus of this side were slightly softened; as
were also the septum lucidum, the fornix and corpus callosum. The last
less so than the other two. There was an ounce or two of serum in the
lateral ventricles, and a small portion under the arachnokl of the right hemi-
sphere. The cerebellum was somewhat softened, but notin so great a degree
as the cerebrum. The cineritious portion was here much softer than the
medullary, and the left side was perhaps a little more altered than the right.
The medulla oblongata and upper part of the spinal cord were normal.

Abdomen. There was red softening of the mucous coat of a portion of the
middle and back part of the stomach; and the pyloric extremity was of a
slate colour and softened. The colon and rectum exhibited marks of acute
inflammation. There was red softening and ulceration of the mucous coal.
The ulceration was not so extensive as is frequently observed; but was quite
sufficient to account for the death of one with a constitution as much impair-
ed as his was. The liver was of a dark purple colour; and nearly all the
yellow medullary matter had disappeared.

Genitals. The testicles on examination showed the two _^surfaces of the
tunica vaginalis of both sides, adherent over their whole extent. There
was no other disease of the right one. It was perhaps rather smaller than
usual. 'J’he left was manifestly in a state of atrophy. It was much smaller
than the right. When cut into, but a small number of the tubuli seminiferi,
could be seen betw'een the anterior surface of the organ and the epididymis.

Remarks. The disease of the brain was amply sufficient to account for
the hemiplegia and mental disturbance. M. Foville informs us, that in
acute cases of madness, he has never observed adhesions of the membranes
to the cortical substance, but that such adhesions are very frequent in
chronic cases. This he imagines will explain the curable nature of recent
maniacal affections, and the hopeless and incurable state of those who have
long laboured under madness or dementia.

A large majority of those who die in this institution have been long
addicted to habits of intemperance; and in every instance more or less of
the effects of chronic gastritis is discovered. According to M. Andral the
shades of colour which principally belong to this disease, are the gray slate
No. XLVIll. — -August, 1839. 28

326 Annan’s Baltimore Alms-House Hospital Beport.

colour, the brown colour, and the more or less deep black colour. These
discolourations, with preternatural redness, and thickening and softening of
the mucous membrane, are the common morbid appearances.

The adhesion of the two surfaces of the tunica vaginalis testis indicated
the previous existence of inflammation. Those pathologists who believe in
a close sympathetic connection between the cerebellum and the testicles,
would ascribe atrophy of the left testis to the morbid state of the left hemi-
sphere of the cerebellum. I do not think that this connection is as yet suf-
ficiently established to justify such an inference. Neither is it necessary in
the present case. The evidences of previous inflammation would satisfac-
torily account for all the morbid appearances.

Apoplexy — Palsy. S. P., setat. 30; habits intemperate; admitted May
12th, 1838. Three days ago, while intoxicated, he fell down in a fit, and
remained in a state of insensibility for two hours. On regaining his senses,
he found his right side partially paralysed. He can drag his leg along with
some difficulty, and move his arm in an imperfect manner. Has no pain.
Functions natural. He was bled, purged, and blistered on the back of the
neck; and in four or five weeks was sent out of the hospital, still limping a
little. Three months after, he was attacked with enteritis, for which he
was bled, cupped, &c., and when in a state of convalescence, he was sud-
denly seized with a chill, to which fever succeeded. He now lost all
power of voluntary motion; his speech was embarrassed, and his faeces t^nd
urine passed involuntarily. He was cupped, blistered, and purged; and
became greatly emaciated and debilitated. Sloughs made their appearance
on the sacrum, and right ear. His teeth and lips were covered with sordes.
Pulse small and feeble, and his appetite gone. By degrees these symptoms
abated. His pulse became natural. The slough separated, and the ulcers
healed; and his general health became pretty good. The paralysis, how-
ever, still continued unabated. About the beginning of December, he had
so far recovered the power of moving the left arm as to be able to feed him-
self with some difficulty. He did not regain the use of his legs, and was
unable to stand or walk. He also continued to pass the fseces and urine in
bed; and he could not articulate so as to be understood, except by those
accustomed to his mumbling and muttering. The sensibility of skin w^as
natural, and continued so to the last. In the beginning of January, 1839,
his remaining strength began to fail, and he died on the 21st of that month.

Autopsy. The brain alone examined. There was slight opalescence of
the arachnoid, and a small quantity of serum effused underneath it. The
ventricles contained about an ounce of clear serum. There were a few
hydatids in the choroid plexus. The left optic thalamus presented in its
central part, two cavities, each half an inch in length, by three lines in
breadth. They were at the distance of half an inch from each other.
Their w^alls were of a dirty yellow colour, and soft. The softness and
discolouration, did not extend more than two thirds of a line into the sub-
stance of the brain. The right optic thalamus, about its centre, also con-
tained a cavity, about as large as a cherry stone, similar in every respect to
those just mentioned. The pons varolii, when opened through its centre,
exhibited a fourth cavity, half an inch long, and three lines broad. At the
point of bifurcation of the basilar artery, there was an aneurismal sac, of
spherical shape, half an inch in diameter. The walls of the sac were thick-

Annan’s Baltimore Alms-House Hospital Report. 327

enecl by the effusion of lymph; so that when emptied of its contents, it did
not collapse. Some small patches of the coats of the basilar artery were
likewise thickened.

Remarks. We have in this case a well marked example of the effects
of habitual drunkenness upon the brain. The constant excitement had
produced disease of the arterial system, and at length vessels were ruptured,
and blood effused into the left optic thalamus. The ordinary processes of
absorption of the extravasated fluid, and cicatrization of the lacerated brain,
took place; and imperfect restoration of the function occurred. The fever
which preceded the second attack of paralysis was probably brought on by
sleeping with the windows raised. Whatever may have been the cause,
it was during the excitement of the hot stage, that rupture of blood vessels
again took place, in the right optic thalamus, and pons varolii, producing
general palsy. The energies of the system were, however, again roused,
and absorption and cicatrization were a second time effected; but the reco-
very was now much less complete; and the vital functions were so imper-
fectly performed, that he at length succumbed.

The seats of all the injuries were in the course of the motor tracts, and
hence motion alone was impaired. The cavity in the pons varolii occupied
its anterior part, and consequently did not involve any of the fibres of sen-
sation.

Apoplexy — Palsy. G. B., aetat. 40, of robust frame, has been an
inmate of the house for the last ten or twelve years. About the time of his
admission had an attack of apoplexy, which was succeeded by paralysis oi
the right side. He recovered so far as to be able to walk about with the
assistance of a cane, and to perform various menial duties. His general
health was good. On January 21st, 1839, while engaged at his ordinary
work, he staggered and fell, and was brought into the hospital in the fol-
lowing condition. There were violent convulsions of the whole of the right
side, with complete paralysis of the left side. The mouth and head were,
with intervals of a few seconds, drawn spasmodically to the right side.
His consciousness was perfect; but his articulation embarrassed. He com-
plained of pain of the head. Pupils were not affected. Pulse slower than
natural, and labouring. He vomited a full meal, which he had taken a
short time previous to the attack.

About forty ounces of blood were taken from his arm; during the flow of
which, he had an evacuation from the bowels, consisting principally of
undigested beets, which he had eaten the day before. Three drops of croton
oil, and a purgative enema were administered, which operated freely; and
a blister was applied to the back of the neck, which also acted well. No
improvement, however, followed these remedies; the symptoms became
worse; and he died forty-eight hours after he was attacked.

Autopsy^ twenty-eight hours after death. Brain alone examined. On
removing the cranium, the sinuses of the dura mater were discovered to be
very much gorged with black blood. The inner surface of the cranium,
particularly along the course of the superior longitudinal sinus, was covered
with drops of this fluid. The glandulae pacchioniee were in great number.

328

Annan’s Baltimore Alms-House Hospital Report.

and largely developed. The pia mater was very much congested. There
was some effusion of dark coloured blood on the summit and outer face of
the left hemisphere of the cerebellum; and a small quantity along the infe-
rior and posterior edge of the adjacent lobe of the cerebrum; all of which
had apparently escaped from the fourth ventricle. When the brain was
sliced, and the drops of blood which oozed from the vessels scraped off
with the back of the scalpel, the open mouths of the vessel were very dis-’,
tinct. Both of the lateral ventricles were distended by clotted blood; more
fluid, however, in the left than in the right. The right ventricle contained a
clot as large as a guinea fowl’s egg; and also masses of pulpy brain, coloured
and broken up by an admixture with the blood. The posterior third of the
corpus striatum, and the whole of the optic thalamus of this side, were com-
pletely disorganized by an effusion of blood which appeared to have taken
place from the latter. The walls of the cavity formed by the haemorrhage
were red and softened, to the depth of two or three lines. Where the brain
was yet firm around the cavity, in its immediate vicinity, there were nume-
rous black spots, as large as pins’ heads, caused by extravasated blood. No
vessels were visible. The greater part of the blood in the left lateral ven-
tricle was fluid. The septum lucidum was ruptured in two places; near its
anterior part, and at its middle; and a free communication was thus formed
between the two ventricles. At the anterior part of the optic thalamus of
the left side, just at its junction with the corpus striatum, there was a cavity
about six lines in length, and from two to three lines deep, evidently the
consequence of the former effusion of blood. It w'as lined by a firm, rugose
membrane of cellular tissue, of a pink colour. There was an aperture by
which it communicated with the ventricle. The substance of the brain
around this cavity was much darker, and a little softer than the rest of the
cerebral mass. The choroid plexus contained a large number of hydatids,
some as large as a pea. That part of the optic thalamus of the right side,
which forms the lateral wall of the third ventricle, was lacerated, presenting
a circular opening of four lines in diameter, its edges ragged and soft, and
the cavity filled with coagulated blood. The third and fourth ventricles
were both distended by this fluid. The rest of the brain presented nothing
remarkable.

Remarks, In this, as in the former case, there were traces of an old
effusion of blood, which satisfactorily explained tlie first apoplectic attack.
The lime which intervened between this and the fatal seizure, was unusually
long. Serres and Foville assert, that lesions of the corpus striatum and
anterior parts of the brain are followed by paralysis of the lower extremi-
ties of the opposite side, and that lesions of the optic thalamus, or posterior
parts of the cerebrum, cause paralysis of the upper extremities. The optic
thalami, in both the foregoing cases, were the principal seats of injury,
and the lower extremities were as much, or more affected than the upper.
There was also, it is true, in the former case, effusion into the pons varolii,
which renders it somewhat ambiguous, as we cannot know the precise time
at vv'hich it occurred. There is, however, a strong probability that it did
not take place until the second attack, when general palsy made its appear-
ance. We can scarcely imagine it possible for eff’usion of blood to be made
into the middle of the anterior part of the pons varolii, where the moiory

Annan’s Baltimore Jllms-House Hospital Report. 329

fibres are concentrated into a narrow space, without general palsy being the
consequence. Supposing then, that the effusion into the pons varolii
occurred at the second seizure, we have the lesion of the left optic thalamus
to explain the original palsy of the right side. The lower extremity was
as much affected at this time, as the upper, which is in opposition to the
views of Serres and Foville.

In tlie latter case, we have the lesion of the left optic thalamus, to account
for the hemiplegia of the right side. Both leg and arm were here involved.
But it may be said, that it was the anterior part of the thalamus, adjacent
to the corpus striatum, which was the seat of the injury. It is impossible
to tell how far the corpus striatum may have been disturbed by the pressure
of the extravasated fluid, when first poured out; neither can we say with
certainty, to what extent the functional action of this part remained imper-
fect, in consequence of the derangement of structures around the cavity,
which resulted from the primary lesion. Additional facts would seem to be
required to establish the supposed connection between the anterior parts of
the cerebrum and the lower extremities; and the posterior portions and the
upper extremities.

Syphilis — Phagedenic Ulceration — Jlneurism of left internal Iliac Artery.
R. C. aetal, 32, was admitted into the female syphilitic ward, September 25th
1838. On the inner side of both nymphae there is an extensive ulceration,
passing a short distance into the vagina. This ulcer has a dark, foul,
unhealthy appearance. Her general health is considerably impaired, and
she is much emaciated. Pulse frequent, small and feeble. Emollient
fomentations were applied to the sores, and infusion of Colombo, gentian, and
chamomile flowers, was ordered. The ulceration, liowever, proceeded until
both nymphae were destroyed, as also the meatus urinarius, and the soft
parts up to the clitoris. It likewise extended fully an inch into the vagina,
burrowing behind the rami of the pubes and eschia on both sides, forming an
immense cavity. She was now put upon extract of cicuta, of which she
took five grains three times a day; and by keeping the parts clean, by fre-
quently injecting tepid water, the ulcerative process w'as arrested, and
healthy granulations sprung up, with every appearance of speedy cicatriza-
tion. At this time she was attacked with haemorrhage from the left side of
the ulcer, behind the rami of the pubes and ischium; at first in small quantity
but recurring at intervals of a few days, and requiring the use of pressure by
passing a piece of sponge into the cavity, formed by the ulcer. In this way
the bleeding was easily restrained. The ulcer on the right side cicatrized,
while that on the left was kept open by the occasional occurrence of the
haemorrhage. She continued in this state for four or five weeks, gradually
becoming weaker, and died the 23d of November

Autopsy. Emaciation great. Both of the nymphae are entirely destroyed.
On the left side, opposite the os externum, there is a superficial ulcer, one
inch wide, and extending from the posterior commissure to tbe mons veneris;
about the centre of which, on the inner side of the rami of the pubes and
ischium, there is a fistulous opening, three lines in diameter.

Oil opening the abdomen, a considerable quantity of coagulated blood was
found in difl'erent regions of this cavity, in the hypogastric right and left

28*

330 Annan’s Ballimore Alms-Home Hospital Report,

iliac, and right hypochondriac — forming, in the latter situation, a layer of
four or five lines in thickness, between the convex surface of the liver, and
the walls of the abdomen. The uterus is a little hypertrophied, and is
pushed from its natural position, far over to the right side, by a tumour formed
in its left lateral ligament, through which the effusion into the sac of the
peritoneum had taken place. The tumour when opened was found to con-
tain a mass of clotted blood, in the centre of which, there was a portion of
dense, lancinated fibrine, about the size of a hen’s egg. It contained & cavity
an inch in diameter, which communicated above with the internal iliac
artery, the coats of which, as high as the ilio-lumbar artery, were thick-
ened, and easily lacerated. There was a sinus passing from the aneurismal
tumour to the vagina; and opening on the surface of the ulcer, inside of the
pubes and ischium. Mostof the branches of the internal iliac were destroyed
at their origin. The sciatica nerve was surrounded by indurated cellular
membrane, where it passes over the short rotations of the thigh; and its
roots were enveloped by coagulated blood.

Remarks, Phagedenic ulceration is one of the most dangerous and un-
manageable forms of syphilitic disease. It is almost always rendered more
inveterate, and more rapid in its progress, by mercury. The antiphlogistic
treatment, with anodynes, to allay irritability, is unquestionably best adapted
to arrest the progress of this destructive ulceration. Mr. Carmichael, in
his “ Essay on Venereal Diseases,” has given us the best treatise on this
subject. Absolute rest in the recumbent position; venesection in propor-
tion to the extent of the pain, inflammation, and symptomatic fever;
antimonials in sufficient doses to nauseate; warm poultices of bread and
water; warm fomentations, either in the form of stupe, or injected between
the prepuce and glans; opium, hyoscyamus, and cicuta, in sufficient doses,
to lessen pain and irritation, and procure rest at night, are the means he
relies upon during the inflammatory and active stage. Afterwards when it
excites but little uneasiness, and creeps slowly along, healing in one place
while ulcerating in another, the solution of nitrate of silver, in the propor-
tion of one, two, or three grains to an ounce of distilled water, he tells us,
may be of service; or the mercurial black, or yellow washes agree well in
some cases, while in others, it must be admitted, that no application seems
to check the progress of the ulcer.

Stimulating applications, he farther says, are often extremely useful to
sloughing venereal ulcers, such as Venice turpentine, or balsam copaiva,
blended with one or two parts of olive oil, or a lotion composed of one part
of tincture of myrrh, to seven of camphorated mixture. They correct the
foetor of the sloughs, and stimulate the sound parts to cast them off; but
unfortunately, he admits that they have not the power of preventing their
renew^al.

I have never seen permanent benefit derived from stimulating applications.
In one case, where the greater part of the glans penis was destroyed, they
had a full and fair trial, after fomentations and poultices; and it was not until
they were all discontinued, and the sore dressed with dry lint twice a day,

Annan’s Baltimore Alms-House Hospital Report, 331

and washed clean with warm water, before each dressing, that healthful
granulations sprung up, and cicatrization commenced. It then speedily
healed.

In the case of R. C. narrated above, the debility was so great, that tonics
appeared to be indicated. Her general health improved under the use of
the bitter infusion, but the ulcerative process was not suspended. The cicuta,
which I have employed in other cases, was manifestly of great service. I
regard it as the best anodyne in these cases. The dose may be increased to
ten grains of the extract three limes a day, if a smaller quantity does not
answer the purpose.

If the aneurismal tumour had not been present, this woman, in all proba-
bility, would have recovered.. No pulsation was detected, and she made no
complaint which could have led to the discovery of the aneurism. There
was a dull and aching pain about the hip and down the leg, which was sup-
posed to be rheumatic. But even if it had been known that there was aneu-
rism, in her debilitated state it would have been worse than folly to have
attempted to cure it by operation.

Pleiiro- Pneumonia. — T. P., aetat. 42, admitted February 11th, 1839.
Ten days ago, after exposure in a damp cellar, he was suddenly seized with
severe pain of his left side, which was speedily followed by a chill, and
high febrile excitement, accompanied by dyspncea. A young physician was
called in who told him he had a bad cold, and that he had seen cases termi-
nate in pleurisy. He prescribed some powders which induced excessive
catharsis. He afterwards applied a blister to the side, and then a pitch plas-
ter. When he entered the hospital, his expression of countenance manifested
great anxiety and prostration. His respiration was very much embarrassed.
There was complete dulness of the left side of the chest, both in front and
behind; also bronchial respiration and bronchophony, and tracheal rattle.
Pulse 120, small and feeble; discharges from the bowels involuntary. A
blister was applied to the chest. He died at three o’clock in the morning of
the 12th of February.

Autopsy. Thorax. The whole surface of the left lung adhered firmly
to the pleura costalis, and thick flakes of recently effused lymph were spread
over the lower and middle portions of it. About eight ounces of serum were
found in the cavity after the removal of the lung. The pleura lining the
ribs and covering the diaphragm, was intensely red; and numberless minute
capillary vessels carrying red blood, anastomosed freely with each other, iti
the sub-serous cellular tissue, and presented injected patches of various forms.
The pleura pulmonalis exhibited a similar appearance. The whole of this
lung, with the exception of a small portion of the anterior part, which lay
next to the sternum above the base of the heart, was in the second and third
stages of the effects of inflammation. The upper half of the superior lobe
was hepatized. It was solid, and inelastic to the touch; was not crepitous,
and when cut into yielded no bubbles of air; but when pressed, a bloody
fluid exuded sparingly from it. This portion was also filled with granula-
tions, which were very perceptible on tearing the lung; and it was likewise
mottled with black pulmonary matter. The whole of the lower lobe, and
the remainder of the upper lobe were in a state of purulent infiltration.
The reddish, mottled appearance of the hepatized portion, was exchanged

332 Annan’s Baltimore Alms-House Hospital Report,

for a yellowish drab, or stone colour, approaching to sulphur-yellow. On
cutting into it, no granulations could be seen; but a yellowish, opaque puru-
lent matter, oozed from it. The slightest pressure with the fingers made a
cavity, which immediately filled with pus. The texture was extremely soft
and friable. The right lung was normal.

Abdomen. The mucous coat of the stomach was red and softened over
nearly the whole surface. A few patches, at different places, were of the
natural colour. The duodenum was slightly reddened. Thejejunum, along
its whole course, was intensely red, and the mucous coat was also softened.
The redness and softening were continued into the ileum; but in a diminished
degree. The upper part of the colon, in the vicinity of the caput coecum,
was of a light pinkish hue, but was only in a slight degree softened.

Remarks, We here have a strongly marked instance of the defects of our
system of medical education. A young man of fair talents, who had passed
through a full course of medical lectures, and obtained his degree, regarded
the symptoms of the above case, as indicative simply of a “ bad cold;” by
which it may be presumed, if he attached any precise meaning to the terms,
he intended to call it a case of acute bronchitis. Acute bronchitis, how-
ever, does not terminate in pleurisy. That form of it, in which the pulmo-
nary vesicles, and smaller bronchial tubes, are the seats of the inflammation,
passes readily into pneumonia; but does not become a pleurisy. Whatever
opinion may have been entertained of the pathology of the case, it is mani-
fest from the treatment, that it was regarded as one of no great severity. No
blood was abstracted; but purgatives were exhibited to the extent of pro-
ducing hyper-catharsis; and after dea;h w^e find a most intense jejunitis; which
doubtless had been caused by the drastic cathartics. The blister not having
been preceded by blood-letting, must certainly have increased the febrile
excitement; and the burgundy pitch plaster, in a case of acute inflammation
of the chest, was, to say the least, a strange remedy.

Now it must not be supposed that I think the blame should attach solely
to the practitioner in this case. I consider the chief defect to be in the
system of education, under which he obtained his degree of Doctor of Medi-
cine. It is impossible for any man, however great his talents, to become
so familiar with the diversified forms of disease, as not to be perpetually
making mistakes, by merely reading in an office, and attending two or three
courses of lectures, of four months’ duration. Until the course of study is
lengthened, and more diligent and careful attendance upon hospital practice, and
to morbid anatomy and pathology are required, similar blunders will be inces-
santly recurring. In private practice, the opportunities for making post
mortem examinations are so few, that students seldom behold, in a single
instance, the ravages of morbid action; and what is worse, physicians them-
selves cannot discover, and consequently do not profit, by the mistakes of
which they are guilty.

The remedy consists in prolonging the course of study; insisting upon
longer attendance upon clinical instruction; and to have a professor of

Annan’s Baltimore Alms-House Hospital Report, 333

pathology, and pathological anatomy; whose course of lectures and demon-
strations shall be considered of greater importance to the mere physician,
than all the others combi ned.

Dysphagia. — W. C , aetat. 50, habits intemperate, but his health,

previous to his present disease attacking him, was good. Admitted, Decem-
ber 5th, 1838. Six months ago, without any premonition, experienced
some difficulty in swallowing his dinner. There was no pain, nor uneasi-
ness; but the dysphagia gradually increased, and finally compelled him to
seek admission into the Alms-House. He is very much emaciated and
anemic. His appetite has always been good. He swallows fluids better
than he does solids. He takes eight or ten tablespoonfuls of soup, with
bread soaked in it, in rapid succession, when inverted action of the (Eso-
phagus takes place, and more than half is returned. Has no pain nor sore-
ness when he attempts to swallow. There is slight uneasiness and a sense
of obstruction at the top of the sternum; which probably arises from the
distension of the oesophagus by the soup. Pulse regular, but small and
weak; bowels in good order; respiration easy; voice reduced to a hoarse
whisper; fauces inflamed. A probang introduced into the oesophagus,
-.passed to within four or five inches of the stomach, when it was firmly
resisted. Capsicum gargle was ordered for the throat. Ivory probangs of
medium size were passed through the stricture into the stomach, with the
effect of entirely removing the dysphagia. For a short time he improved
rapidly in appearance, and became considerably fatter. From one to two
weeks were sufl’ered to elapse before the operation was repeated, in vsrder
to prevent dangerous irritation. The last time the instrument was introduced,
a small quantity of pus and blood was brought up. The dysphagia was
not very troublesome after this; but in a few weeks he again began to
decline. The inflammation of fauces extended to his tongue; his voice
became more whispering, and he died April 10th, 1839.

Autopsy. About eight inches of the lower part of the (Esophagus was
one ragged ulcer. The mucous membrane was entirely destroyed; and also
the greater part of the muscular coat. The ulceration extended an inch,
into the stomach beyond the cardiac orifice, and terminated abruptly by
raised edges. Three small masses of hard, cheesy matter were found
around the edges of the ulcer, where it terminated in the stomach. Along
the smaller curvature, the stomach was red and softened. The (Esophagus,
in the neighbourhood of the cardiac orifice, and likewise the stomach,
adhered to the liver by effusion of lymph. Where the liver lies over the
oesophagus, there was an hepatic abscess, containing six ounces of black,
thick, soft matter. This abscess did not appear to have opened either into
the oesophagus or stomach. The pharynx was red, and the mucous coat
thickened. The velum pendulum palali was greatly thickened and indu-
rated. The posterior part of the tongue, on its upper surface, had its
covering greatly thickened and indurated; and the papulae were very much
enlarged. The half of the lingual surface of the epiglottis, next its base,
was thickened and indurated; the mucous coat having numerous rounded
prominences on it. The larynx was free from disease. The lungs were
large and contained a few tubercles — probably not more than half a dozen.
The bronchial mucous membrane was somewhat reddened; and the tubes
contained a quantity of frothy mucus.

334 Parry’s Case of Deformed Leg from Fracture,

Remarks. This, I suppose, is an* example of what would be called
scirrhus and cancer of the oesophagus. There was not as much induration
of the tissues, as we usually find where scirrhus degeneration exists; but
this may have been owing to the extent to which the ulceration had pro-
ceeded; by which process, softening had taken place. If the scrofulous
diathesis had been strongly marked, by the deposition of tuberculous matter
in the lungs and other parts, I should be disposed to call it a case of scro-
fuloL’s ulceration. But as this was not the fact, and as the lumps taken
out of the margins of the ulcer, in the vicinity of the cardiac orifice of the
stomach, were harder than tuberculous matter ordinarily is, it may safely be
called carcinoma.

If the patient had lived long enough, the hepatic abscess would certainly
have burst either into the stomach or oesophagus.

We here also have an instance of remarkable change of the voice without
disease of the larynx. The thickening of the velum pendulum palati, and
epiglottis, and the inflammation of the fauces, appear to have been sufficient
- to reduce the voice to a hoarse whisper, precisely similar to the state in
which I have repeatedly observed it, when the vocal chords have been found
tumefied and indurated, on examination after death.

Baltimore, May 1st, 1839.

Article VII. — Successful Operation for the purpose of remedying a

Deformity of the Leg; consequent to a badly set Fracture, By

Charles Parry, M. D., of Indianapolis, Ind.

The patient, upon whom this operation was performed, was a young man
near the age of 22; a member of the bar, of fine talents, and considerable
attainments.

The history of the case is as follows: — At the age of fifteen, while skating
on the ice, he fell and broke his right leg; the tibia about midway, the
fibula two inches lower down. The physician who was called to attend the
case, was considered skilful, but of intemperate habits, and, most unfortu-
nately for the patient, was intoxicated at this time.

In what manner he dressed the fractured limb, it is impossible to say;
but in the course of three or four weeks, it was found quite firmly united:
the bones forming an angle almost equal to a right angle, at the place
of fracture. The patient had to walk with a crutch, the toes of the lame
limb not touching the ground when he was in the erect position. When
he sat on a chair, and placed both feet on the floor, the knee of the sound
limb was five inches higher than the knee of the lame one.

After suflTering in this situation near two years, the patient determined

335

Parry’s Case of Deformed Leg from Fracture,

to consult some of the most eminent physicians through the country, in
order if possible to have his situation alleviated. But they generally
advised him to have nothing done; which advice he followed with all
fortitude, for two or three years more; during which time he suffered such
great inconvenience, that he finally concluded to make another effort, and
determined to endure almost any pain, or submit to any plan of treatment
that offered a feasible prospect of relieving him.

For this purpose, he went to Cincinnati, and consulted several physicians
of that place; the most of whom again advised him to have nothing
done, as they did not see much prospect of his obtaining relief. One or
two, however, proposed to endeavour to break the limb over again, with
the view of setting it straight. The patient being a person of strong mind
and quick apprehension, was not satisfied of the practicability of this pro-
ject; and as it was merely proposed and not urged with any warmth by the
physicians themselves, it was not adopted.

The patient returned home; pursued the study of the law; was admitted
to the bar; and commenced a lucrative practice. But still dissatisfied in his
mind, (as he has frequently told me,) believing that something might yet be
done to relieve his situation, and determined to submit to the first proposition
that offered a probable chance of the desired result.

In this state of mind, 1 met with him in the summer of 1837; became
intimate with him, when he gave me the history above related; and asked
my opinion of his case.

After some deliberation, I stated that I thought he could be very materially
benefitted by the following operation.

To cut down to the bones; dissect the muscles from them, and saw a
little block out of the angle of each bone; bring the lower end of the limb in
a line w’ith the upper; retain them in juxtaposition by splints; and treat as
a compound fracture.

As it was only necessary to convince the patient of its practicability, to
have the plan adopted; he told me at once, I should operate, as soon as he
could make arrangements for his necessary confinement.

My reasoning on the subject was thus: after the operation the case would
be similar to a compound fracture, with probably less violence to the soft
parts; that compound fractures, now a days, were generally succesfully
cured, without a resort to amputation as formerly. I also, had in my
mind the operation of Dr. J. Rhea Barton of Philadelphia, on the hip
joint. I concluded the violence to the general system in this case would
not be greater than in his; that if he could succeed in establishing an artifi-
cial joint, I certainly might succeed in forming a natural union; and let the
worse come, the patient could not be a loser, for I could yet amputate, and
the patient had repeatedly told me, he would rather have his leg cut off,
than remain as he was.

Oil the 15th of January, 1838, assisted by Drs. Mason and Ford, others

536 Parry’s Case of Deformed Leg from Fracture,

present, I proceeded to the operation already described. I had prepared
myself with a small saw, from the plate and description of Dr. Barton’s in
his hip joint case, without which I would have found great difficulty in
sawing the fibula; from its being so closely and firmly fixed against the
outward flat surface of the tibia, and covered by the tibialis anticus muscle.
Further, without this small saw, it would have been difficult to avoid
wounding the anterior tibial artery;- for, while severing the fibula, I had to
introduce the end of a finger between the artery and bone; and permit the
saw to strike against my finger.

In sawing the fibula, I had made my calculations for the two sections to
meet at the posterior part of the bone; but after the block of bone was taken
out, 1 found the leg would not yield to moderate force. I then took off
another section from the lower end, the appearance of which indicated that,
at the original fracture, a very thick spicula of bone had extended across the
angle, acting as a brace; the triangular space being filled up by osseous
deposition. After this was overcome, the limb was brought straight with-
out further difficulty.

By this operation, the leg was increased three inches in length.

January 16/A. During the forepart of the night the patient rested badly;
complained of much pain; on taking a large anodyne, about one o’clock,
rested much ’better till morning.. The leg was kept in its proper position
very snugly. This morning, 16th, seemed quite smart; pain trifling. About
eleven o’clock chang^e for the worse; such as increased pain in the wound,
with sensations of smothering; burning at the heart; followed by a slight
chill and subsequent fever; gave a mild cathartic of blue mass, and rhei.
Rested tolerably during the afternoon. Medicine operated at nine in the
evening; took a portion of salts; operated at one; after which, slept well
until morning.

\lth. Quite smart this morning; relished his breakfast; no pain except
on moving the limb; during this afternoon and evening, suffers much
from “ starts and jerks,” as he calls them, in his sleep, otherwise there is
but little pain while the limb is still; says he is afraid to go to sleep for fear
of its jumping so, which sometimes causes him to scream out with pain;
during the night suffered excessively from starts; gave large anodynes, did
not allay them, however; gently rubbing the thigh, with my hand, was the
only thing that allayed them; and while that was continued, he slept easy
and free from starts; a passage at nine 9 o’clock.

\Sth. No material change; suffers a great deal of pain; removed a portion
of the dressings, which afforded some relief; got up and set in a chair, while
the bed was made; slept during the night better than usual.

19//i. Still improving; leg not so painful; some swelled; pus; looks very
healthy.

23cZ. The leg has been gradually improving until this morning, when
from some unacco unstable cause, the system became too much relaxed and

337

Parry’s Case of Deformed Leg from Fracture,

weakened; the wound has a bad appearance, and gaping; granulations of a
leaden colour. Gave quinine freely, generous diet, and stimulating applica-
tions to the wound, &c.

25/A, 26/A, 27/A. Improving finely.

28/A. During the morning felt better than he has been at all; but in the
afternoon met witli a very serious accident; felt very smart; had a number of
his acquaintances in the room, paying him a visit; was sitting up in bed,
scratching his leg, as it itched considerably, when upon reaching too far to
scratch his foot, and suddenly throwing the w^eight of his body forward, he
broke up the new adhesions of the bones, and deranged their position; this
caused him so much pain that he nearly fainted. Some hemorrhage proceeded
from the wound; I found it impracticable to adjust the bones at this time,
from the excessive pain the least motion produced.

29/A. Very restless last night; appears to labour under extreme morbid
sensibility. Says the snapping of a penknife, or the jar of a glass tumbler,
shocks his w'hole body; during the night troubled in an unusual degree, with
starts and jerking, this morning leg very much swollen. Large anodyne;
poultice to the wound.

30/A. Swelling of the leg increased; pain excessive; seems very drowsy,
probably owing to the large portions of anodyne he necessarily took last
night. Cathartic, poultices continued.

31s/. Seems every way better; swelling reduced; with the assistance of
Drs. Mason and Ford, 1 reset the leg.

February^ Is/, 2d. Tumefaction running high again.

3(/, 4/A. Jerking excessive; tried enormous doses of anodyne equivalent
to xij. grs. of opium at a time; repeated frequently; this not able to suppress
it, nothing but the rubbing of the lame thigh does any good.

15/A. Patient gradually and slowly improving; sets up most of the day
in an arm chair; gets about the room with the aid of a crutch.

21th. Patient improving finely; v ent out of doors and walked up town
with one crutch; is able to bear considerable weight on the lame foot.

March. Tow'ards the last of the month, patient started on a trip to Wis-
consin Territory to examine the country; went by water.

Remarks. I am fully satisfied that, in this case, mine was the only prac-
ticable operation that could have been performed. Had the limb been put
in the pullies, as proposed by the Cincinnati physicians, I am confident the
leg would not have broken at the desired place, from the great thickness of
osseous matter there; but probably, if they persisted, w’ould have broken,
two inches or so, either above or below, which would have made the leg
even worse than before. However much I had to regret the accident that
befel the patient in the displacement of the bone, I have nothing to reflect
upon myself from neglect, or otherwise, as it w'as entirely the patient’s
fault, his own accident; I deeply regretted it, because it gave him so much
additional pain, and put him back three or four wrecks, when he was doing
No. XLVHI.^ — August, 1839. 29

338 Parry’s Case of Deformed Leg from Fracture,

well, and had passed the worse period of confinement; and we were unable to
fix the leg as straight as before the accident. I consider there was no position
more favourable for the displacement of the bone, than the one he was then in,
sitting up in the bed laughing with his associates, the heel resting on a firm
foundation, and the only support under the wound was a bunch of cotton,
as we had just taken the most of the dressings off, for the purpose of gently
scratching the limb, which itched intolerably. In this position, suddenly
throwing the body forward, putting into a state of tension the muscles
inserted into the tibia and fibula, at the same time sending an impetus or
force along the femur; from it continued to the bones of t-he leg; the heel
could not sink, but the bones did at the wound.

I was highly gratified by meeting with the report of Dr. J. Rhea Barton’s
anchylosed knee case, in the February number of the American Journal of
Medical Sciences; where the principles in surgery that are involved, and
their applications to the benefit of his patient, is exactly the same as in
mine, modified only in situation. At the time that I operated, I had never
heard of his operation, although it had been performed more than two
years previous, but not published until the February following.

Indianapolis i Ind,, March 30^/t, 1839.

[Note. — The preceding case is an interesting one, and the expedient re-
sorted to for the relief of the patient, is highly creditable to the ingenuity of
the surgeon. The plan of treatment, as observed by Dr. Parry, is identical
with that previously adopted by Dr. J. R. Barton, for the relief of a patient
suffering from an anchylosed knee. It is probably not generally known, that
operations of a similar character have been also performed in Europe: the
following notice of three of them, all that we know of having been recorded,
may be therefore considered as an interesting complement to this paper.

M. Clemot, surgeon in chief of the marine at Rochefort, has, in two instances, made
resections of portions of the femur, in order to remove great deformities resulting from
fractures badly treated. The first case was in a child in whom the treatment by exten-
sion, though persisted in for several months, had failed. The operation was performed in
December, 1834. A longitudinal incision, two inches in length was made over the
callus, and the bony angle fairly exposed. The fragments had united at an angle of
about 112 degrees. Spatulas were placed beneath the bone in opposite directions in order
to protect the soft parts, and the angular projection protruded. With a small saw, a sec-
tion perpendicular to the axis of the superior fragment was made, including but two
thirds of its thickness. A like section was then made for the inferior fragment. The
loss of substance was not great, and was at the expense of the callus. The limb was
then placed in a good position, and the fragments maintained in apposition. Seventy
days after the operation the child was removed to Bordeaux, having the limb straightened
and lengthened.

The second case, was that of a husbandman, aetat. 27, who, fourteen months and a
half previous to the operation, had met with a fracture of the left thigh a little above its
middle. After the cure, the femur remained deformed, and bent to an angle of 130
degrees — the summit of this appearing at the external and anterior part. The limb
was shortened five inches, the leg and the foot carried inwards, and the patient unable

339

Parry’s Case of Deformed Leg from Fracture,

to v/alk. The callus was perfectly firm. Resection of the angular projection was made
in February, 1835, and the limb afterwards placed on the double inclined plane. Seventy
days after the operation, the inclined plane was removed, the leg and thigh being still
kept in a stale of semi-flexion, but slight motion allowed. The date of his discharge is
not mentioned, though it is stated that he was able to support the weight of his body on
the limb, and had a lameness scarcely perceptible.

The above cases are extracted from a memoir by M. Clemot, entitled, “(Swr la resection
du femur pour un cal vicieux^" presented to the Academic de Medecine of Paris, 24th of
May, 1836.

M. Wasserfuhr of Stettin has also performed a nearly similar operation on a child aetat.
5, to remedy an angular deformity of the femur above its middle part, following a badly
treated fracture. In his case, the fractured bone was consolidated in such a manner as
to form nearly a right angle, and the limb was shortened to the extent of twelve fingers
breadth. The operation was difficult, and followed by severe symptoms, but the patient
recovered.*

Since the preceding was written, we have received the No. of Guy’s Hos-
pital Reports for April, 1839, and find in it an account of a similar operation
recently performed by Charles Aston Key, Esq. for the cure of deformity
of the tibia, occasioned by a gun-shot wound.

The subject of this case. Captain Charltra, had the tibia of his right leg fractured by
a musket ball, on the 17th of August, 1835, in Assam, East Indies. “ It appeared, from
the history of the accident and subsequent treatment, that a considerable portion of bone
having been lost on the inner side of the tibia, the broken ends had united at an angle,
in the same manner and fi’om the same cause as an ulcerated spine acquires an irregular
form from loss of substance on the anterior part of the vertebrae. The upper part of the
tibia had not only formed an angle at its point of union with the lower portion of the
bone, but also deviated from its natural line in relation to the femur. Its head, with
the articulatory surface, had been somewhat forced outwards, so that an appearance of
obliquity was given to it when viewed from before. In addition to the great deformity
of the tibia, the fibula had undergone a displacement at its upper extremity. Its head
had been forced away trom its articulation with the tibia, and formed an unnatural pro-
minence, above the usual position in reference to the tibia. The bearing of this bone
was also altered. Not having been broken at the time of the accident, it could not
yield and form an angle, as the tibia had at the seat of fracture; but maintaining
its natural straight line, it had been compelled to alter its line of bearing, in com-
pliance with the angular form of the larger bone. The fibula, therefore, preserved
a line parallel to the lower portion of the tibia. Its lower end, being forcibly acted on
by the inward inclination of the foot and lower part of the tibia, had carried the upper
part outward; and had caused a dislocation of its head, which had undergone some
change of form, and possessed a degree of motion not natural to it in its ordinary position.
The shortening of the whole limb occasioned by this alteration in form, was such as to
cause Captain Charlton to walk on his toes; the heel being raised an inch and a half
when he stood upright. The soft parts had a healthy aspect; and the cicatrix over the
bone had not contracted a firmer union to the periosteum than is usual with wounds situ-
ated directly over bone.”

The limb was useless; the patient was obliged to carry it at some distance from its
fellow in the act of progression. Sir Astley Cooper and Mr. Key were consulted as to

* We are indebted for the above abstract of these three cases to our colleague Dr. G. W. Norris.

340 ' Parry’s Case of Deformed Leg from Fracture,

the possibility of restoring the natural line of the bones of the leg; and the former sug-
gested as the only means of restoration, that the bones of the leg should be divided —
doubting whether the division of the tibia alone would be sufficient to set the fibula at
liberty; — but that the tibia should be first divided; and if necessary, the operation should
be performed on the fibula. As the muscles were not apparently in fault, this course
promised the patient relief. They seemed to have acted only from the tibia having lost
its support on its inner side, and consequently to have drawn the foot and the lower half of
the leg inwards. Their fibres did not appear to have undergone any permanent shortening.

The operation was performed by Mr. Key, on the 14th of October, 1838. “The tibia
was laid bare on its anterior surface, by a longitudinal incision nearly four inches long,
which traversed the line of the old wound, and allowed the integuments to be detached
on each side; so that the anterior spine and the attachment of the soleus were exposed,
just above the site of the old fracture. A strong steel grooved director, slightly curved,
such as I use in operating for hernia, but narrow, was then passed along the outer sur-
face of the tibia, detaching the tibialis anticus, until it reached the unyielding interosse-
ous ligament. By a little firmer pressure, the director pierced it close to the bone. With
another similar director, and by the same process, the inner and back surface of the
tibia was so far detached from its muscles, that the ends of the two directors met behind
the bone.

“A curved needle, on which was hooked a chain-saw, was then passed along the groove
of the outer director, and from thence to the groove of the inner; and its point being
brought to view by a pair of dressing-forceps, the saw was adjusted so as to cut the bone
from behind. When the tibia was about half sawn through, the saw — as chain-saws too
often do, even when lightly used — locked, and became useless: the section of the bone
was therefore completed from before, by a small common saw.

“ As soon as the tibia was divided. Sir Astley Cooper, taking the foot in his hand,
found the lower part of the leg quite free to move in any direction, and that it was unne-
cessary to divide the fibula. As soon as the tibia was brought into a straight line, the
head of the fibula was restored in some measure to its natural position, and ceased to
project in the unseemly manner it had done before the operation. The part where the
tibia was divided, gaped, as soon as the bones were straightened; and the point of con-
tact between the sawn ends of the tibia was but a small portion of its outer circum-
ference. The muscles had, from length of time, acquired so fixed a state, that some
force was required to overcome their resistance: for as soon as the hand was removed
from the foot, they immediately carried it inwards, to its former position.

“ The limb was allowed to rest on pillows, without much restraint: it being thought
advisable to allow the wound to pass into a healthy state of granulation, before any
attempt was made to confine the bones with splints. At the end of about ten days the
wound had quietly gone through its several stages, and had healed, with the exception of
about an inch in the centre: this part continued more or less open for some weeks; dis-
charging a healthy pus, and giving exit to a few minute portions of exfoliating bone.
The inflammation that succeeded the operation, was less than might have been expected;
and the constitutional disturbance was inconsiderable, owing, probably, to the natural
temperament of the patient, and his long previous preparation. The suppuration seemed
to be confined to the periosteum and ends of the bone; the surrounding soft parts remain-
ing almost free from pain and tumefaction.

“ The object to which it was necessary to pay close attention, during the progress of
cicatrisation, was to counteract the resistance of the muscles, and to prevent contraction
at the cicatrix when union had taken place.

“ The limb, throughout the whole treatment, was kept upon the heel, with the knee
straight. At first, two long lateral splints, well padded, were applied, so as to embrace

341

Magill on Scarlet Fever,

the foot on each side: to these were added, afterwards, an under splint, to give more
effective support and steadiness to the limb. The constant tendency to displacement,
was not effectually prevented by common tapes and bandages: as these became slack,
the leg assumed its former distorted position; and thus motion was given to the broken
ends of the bone, in adjusting the line of the limb. To avoid this, which was not prac-
ticable by means of straps or bandages, a tourniquet was applied at either end of the
splint. The length of lever enabled the upper tourniquet to act with great power
on the foot, and to keep it in a straight line with the thigh. The lower one was
kept firmly screwed to the heel of the two splints; thus keeping the foot firmly secured,
and giving steadiness to the action of the upper tourniquet. This plan of keeping the
tapes of the tourniquets tight prevented motion or displacement in the ends of the bones.
It was at one time contemplated to substitute the white-of-egg bandage, in place of the
splints; but the attempt was unsatisfactory, as displacement of the limb gradually took
place; and we were compelled again to have recourse to the method which had answered
our purpose so well, with the addition of a long outside pad on the fibula.

“The process of union and of consolidation, was necessarily tedious, from the limited
points of contact between the sawn ends of the bone and the space which had to be
filled up on its inner part. It was not till the beginning of January, that union could
be said to have taken place; as before that time, the limb would slightly yield, when
released from the splints. On the 18th of January, the wound having been some time
closed, and the bone seeming to be firmly united. Sir Astley Cooper, in the presence of
Mr. Atkins and Mr. Balderson, who had unremittingly watched the progress^ of the case,
made a careful examination of the leg, and pronounced it to be united and firm. The
fibula, though deviating but little from its usual appearance, had not become quite firm
in its new position; the ligaments remaining weak, and unable to sustain it without
allowing some slight lateral motion. It was deemed advisable, while the external callus
was forming and acquiring firmness, to continue the splints with common bandages and
fillets.- This precaution was also rendered necessary, by the possibility of the newly-
formed cartilage contracting before bone had been deposited in sufficient quantity to give
it solidity. The length of the limb appeared little less than its fellow, when they were
laid together parallel to one another.”

On the lOth of March, 1839, the date of the last report, the leg continued in good
position; but the cicatrisation of the wound had been retarded, by the coming away of
several small portions of bone; in other respects, the patient was doing well.— ed.]

Article VIII. Notice of the Scarlet Fever as it occurred in the Valley of

Virginia and in the counties of Loudon and Fauquier in the year 1832;

and of the Treatment which proved the most successful. By H. D.

Magill, M. D., of Virginia.

In the year 1832, the scarlet fever made its appearance in the northern
counties of the Valley of Virginia; and extended its ravages across the Blue
Ridge mountains, into the contiguous counties of Loudon and Fauquier. It
was attended with dreadful fatality.

The depleting plan of treatment was at first universally adopted in the
Valley. In some instances, during this mode of treatment, the patient sunk

29*

342

Magill on Scarlet Fever.

under the first bleeding, and either died immediately or languished for a
few days in a state of hopeless debility. In other cases the free operation
of cathartics given to reduce inflammatory action seemed to exert a highly
deleterious influence by prostrating the afflicted. In many instances when
depletion was used under the most favourable circumstances, gangrene, and
sloughing, ensued in and around the orifice made by the lancet; and it was not
an uncommon occurrence for blisters to mortify.

But it might be asked; what was the condition of the patient subjected
to this plan of treatment? was depletion contra-indicated by the symptoms?
Not at all; the symptoms seemed imperiously to call for such a course.
The pulse exhibited a high grade of arterial action, the brain appeared
to be frequently in a state of congestion; generally there was considerable
delirium and occasionally much oppression about the pulmonary regions.
Bloodletting and free purging appeared to be absolutely necessary in order
to reduce the excitement to a proper standard; in some cases it seemed to be
required, to prevent disorganization of the brain on the lungs, threatened by
violent excitement or over-powering congestion.

The writer, residing and practising his profession in one of the Valley
counties at the time, was an eye witness to the above facts. Soon after the
appearance of scarlatina in the Valley, it broke out in the country east of the
Blue Ridge mountains; and showed itself extensively in the counties of Lou-
don and Fauquier. The same system of practice was adopted that was pur-
sued in the Valley of Virginia; with precisely the same results; for the
mortality was frightful. There was one exception to this course;* one
physician had sagacity enough to detect the erroneous views entertained
of the disease, and firmness enough to differ from his professional brethren
in the course he pursued; having adopted the old established doctrines with
regard to the disease, upon which he practised with some modification, and
with the most distinguished success. His loss did not exceed two per cent.
He was frequently called to the aid of those who pursued the depleting plan,
and generally by his simple mode of treatment, succeeded in snatching from
the grave, patients who had previously been considered in a hopeless con-
dition. Soon after the great epidemic of 1832, the writer removed from the
Valley to the county of Loudon, where he has since pursued his profession.
Influenced by the ill success of the depleting plan, he has since practised
after the mode pursued by the above mentioned physician, with entire suc-
cess; and can state the fact that whilst death has been common from scarlatina
in the neighbouring counties, and several in this vicinity have died when a
different mode of managing it was adopted, but one has occurred in the
range of his observation, that was treated after this mode. It is proper that
the writer should introduce, previous to entering upon the treatment of scar-
latina, extracts from several letters, in answer to a call for information on the

* Dr. W. L. Powell of Leesburg Virginia.

343

Magill on Scarlet Fever,

subject, and the mode of treatment pursued; as they will confirm the state-
ment made by him. Two will be sufficient. The one is taken from the
letter of a gentleman who stood at the head of his profession in the Valley;
the other is from a physician of extensive practice in the upper part of Lou-
don and Fauquier counties. “ With respect to the treatment (says the
former) I believe I tried every plan recommended by the best writers, and
am equally dissatisfied with them all. The emetic plan recommended by
our old professor Rush failed to arrest the disease, and I think frequently
increased the inflammation of the stomach and throat. The bleeding plan
recommended by Armstrong proved equally objectionable; in the simpler
form it was unnecessary, and in the malignant it prostrated the patient. The
punctures frequently mortified. Cold affusions recommended by Dr. Currie,
moderated the excitement, but failed to arrest the disease. Blisters should
never be applied, they so frequently become gangrenous, that I feel aston-
ished they should ever have been recommended.”

The remarks of the latter physician, above alluded to, are as follows:

“ The number of patients I have visited, since the 1st of April is 136; of
this number I have lost 14;* five died within a few hours after my first visit,
leaving nine with whom 1 had any possible chance. All the cases attended
with cerebral inflammation either in my own practice, or that of others as
far as I can ascertain, died. In my treatment, I have paid no regard to the
name of the disease whatever, but have endeavoured to accommodate the
remedies as nearly as I could to the different grades and symptoms which
presented at each visitT The majority of the cases were of the anginose
kind, and very violent. In these I constantly bled until nausea or faintness
was induced. Next I generally gave an emetic and cathartic combined, and
kept up a catharsis for a day or two, with pretty large doses of calomel;
and during the intervals I gave broken doses of ant. tart.; sometimes muriate
of ammonia in conjunction with calomel and tart. I used cold ablutions very
freely, and often enough to keep down the temperature of the skin. In
using the cold bath 1 paid no regard to the eruption; as this appears to have
no control over the disease; and in very many cases does not make its ap-
pearance at all. I have frequently cupped and blistered behind the ears, on
the back of the neck, and on the chest; but have done so with a trembling
hand, as the latter are generally very hard to cure and once or twice became
gangrenous. So much for our epidemic. I cannot boast of having given
you any thing new or successful.”

Treatment. If called in immediately after the attack, ipecacuanha should
be administered so as to cause free vomiting. Should the first dose not have
this effect, it ought to be repeated until it succeeds. The preparations of
antimony are objectionable, inasmuch as they are calculated to increase the

* This letter was written in June, 1832; how many died afterwards can not be aseer-
tained.

344

Magill on Scarlet Fever,

local irritation of the stomach, which in every severe case amounts almost to
phlogosis. If there seems to be a necessity for keeping up a slight nausea,
it should be done by small doses of ipecacuanha. Much mischief has been
done by the use of tartar emetic in scarlatina.* The writer was lately
called upon to see a case in which paralysis of the stomach existed, evidently
caused by the presence of this article within an inflamed mucous membrane.
After free emesis has been produced, every effort should be directed to the
surface. By bathing the feet and legs, in warm water; and making appli-
cations of hot bricks; and bottles filled with hot water, to the extremities,
and body, in conjunction with warm herb teas, such as an infusion of saffron,
menlha pulegium, hoarhound, &:c. diaphoresis will generally be induced;
which can afterwards be easily maintained, by covering up the patient tole-
rably warm, and continuing the use of the sudorific teas above mentioned.
It will frequently be found necessary, should the tongue be loaded and the
discharge of a light complexion, to give a moderate quantity of calomel in
the commencement; but this should not be repeated unless circumstances
imperiously demand it; inasmuch as the continued use of mercury might
produce an irritable state of the stomach and intestinal canal which would
seriously interfere with the well-doing of the patient. The bowels should be
kept gently open by the mildest and most soothing cathartics, such as the
ol. ricini, of which a small dose may be given every twelve or twenty-
four hours, according to circumstances. In most cases there will be an
evident exacerbation, every evening, accompanied with more or less delirium.
This can generally be relieved by gently increasing the cathartics, putting
the first in warm water, and giving warm herb teas. If the stomach should
be irritable! repeat the emetic as at first administered. In one instance
where the lungs were considerably affected the writer prescribed an emetic
every evening for several days with marked advantage. All the unpleasant
symptoms give way, including the delirium, upon producing diaphoresis by
these means. In cases where the disease obstinately resists every effort to
effect diaphoresis, perseverance in the use of the foregoing remedies will
generally produce it at last. To prevent inflammation of the throat and to
relieve it if it should occur, the mouth, and pharynx should be gargled every
three or four hours, with an infusion of cayenne pepper; and if the patient
should swallow a portion of it, there will be no injury sustained. Should
ulceration supervene, equal parts of the tinct. of Peruvian bark and myrrh
should be used as a gargle. The swelling of the glands may be discussed
by an application of hops steeped in hot vinegar, and thickened into the
consistence of a poultice by bran or corn meal. The diet should be mildly
nourishing and the drinks all warm. It is an important part of the remedial

* The effect of tartar emetic upon a highly irritable stomach is a well known fact.
I feel surprised it should ever have been used in Scarlatina.

t When the vomiting is excessive, it will be promptly checked by the mint julep.

345

Magill on Scarlet Fever.

course that not more than one or two patients should be kept in the same
room. Perfect quietude should be enjoined.

In the commencement of the attack should the pulse be strong and corded, and
should this condition of the circulation be attended with great congestion of
the brain or lungs; there can be no doubt about the propriety of extracting
a small quantity of blood either by cups, or leeches, and even by the lancet;
but generally this stale of things can be relieved by diaphoresis brought on
by the before mentioned means, conjoined with the use of sinapisms; which
should never be suffered to remain on long enough to produce vesication. In
this state of cerebral congestion emesis is produced with great difficulty, but
whenever it can be with facility effected, it generally relieves the brain.

Cases sometimes occur, in which the patient is immediately struck down
as it were, by a sudden prostration of the vital energies. In such cases the
pulse suddenly sinks, the extremities become cold, and the patient appears,
almost insensible. Here the system should be roused by sinapisms, and the
exhibition of an active stimulant,* before an emetic is administered. But
this should always be given and repeated until active vomiting is produced,
so soon as the system appears to be sufficiently revived, for the stomach to
be sensible of the presence of the medicine, and this should be followed by
all the means necessary to keep up a determination to the surface.

Should ulceration and sloughing of the throat occur whatever may be the
state of the pulse, the plan of treatment should be decidedly tonic. The
Peruvian bark in tincture should be freely administered; and very often it will
be proper to make free use of some active stimulant, especially if the pulse
should be weak and failing. When diarrhoea occurs from swallowing the of-
fensive secretions of the fauces, port wine may be given with advantage. After
the disease has run its course, it frequently leaves unpleasant sequences, t
such as suppuration of the glands, dropsical effusions, &c. At the same time
that the remedies peculiar to such affections are freely administered; the sys-
tem should be supported, by a generous but easily digested diet; and the
use of Port or Madeira wines. Should any obstruction of the abdominal
viscera appear to exist, small doses of calomel may be combined with the
squills which is usually given to remove the dropsical swellings. Perhaps
the most effectual mode of restoring tone to the skin, is the use of the warm
salt bath.

But in treating of the secondary symptoms of scarlatina I speak of what
seldom occurs, when the foregoing plan of treatment has been pursued.
That shattered state of the system which gives rise to such consequences
does not often take place, when the disease is managed after this manner.
As a proof of this fact I refer to the experience of those who have tried it.

* Mint julep has been given with great advantage.

+ Dr. Powell avers that he is not often troubled with secondary symptoms in his prac»
tice; and when they do occur they are generally easily removed.

346

Magill on Scarlet Fever.

If called in late, after a different mode of practice has been pursued, par-
ticularly if depletion has been carried to any extent, the proper course would
be to commence immediately with the bark, for it but seldom happens that
depletion does any good unless its effects are immediate. In other words if
the patient does not mend promptly, and decidedly under depletion, we may
always conclude the system to be in an adynamic condition after the attack
has lasted several days. Very frequently in cases so treated, the patient,
drops off when least expected, either by friends or physician. The pulse
may be tolerably firm, and the general indications of strength cheering; still
if the disease is at all severe at this late period, the patient may and does
frequently sink with the greatest rapidity. Death in such cases is generally
preceded by coma; any approach of which should be viewed with the great-
est alarm.

To conclude. In the mild cases of scarlatina, patients will require but
little attention; except to prevent them from being exposed to a draught
of air keeping up a gentle moisture on the surface, and the bowels open;
with ol. ricini, or some other mild cathartic. It would also be advisable to
wash the throat occasionally with the pepper gargle. In the severe forms,
the practitioner’s main object should be to produce diaphoresis and steadily
maintain it; and at the same time counteract the rapid failure of the system,
exhibited in the general, but more particularly, in the local affections, by all
the means previously recommended for that purpose,

Feesbur^^ Virginiat June^

347

MONOGRAPH.

Article IX. On the Principal Diseases of the Liver. By N. Chapman,

M. D., Professor of the Practice of Medicine in the University of Penn-
sylvania.

No organ of the body, is much more curious or interesting in several
respects, than the liver.

Like the stomach, it belongs to nearly every class of animals, and on
account of its early development, its immense size, the peculiarities of its
circulation, its intimate sympathies, as well moral as corporeal, and above
all, from the high functions it performs in the animal economy, it is of our
complicated and wonderful machine so important a portion, that its derange-
ments deserve the utmost consideration.

I. Hepatitis. Commencing with hepatitis, or inflammation of the liver, I
shall, successively bring into view the other affections, which are to claim my
attention.

This disease comes on, for the most part, with the ordinary symptoms of
pyrexia, such as chilliness or rigors — followed by flushes of heat, and finally
fever. Nausea and vomiting are apt to take place, sometimes of bile, though
oftener at first, of tough phlegm — and I have seen it of dark granulated matter,
or of a perfect fluid of the same colour, or there is only a sense of epigas-
tric or praecordial uneasiness, attended by deep sighing, and considerable
jactitation and nervous wretchedness. The bowels are torpid, and the dis-
charges small and costive, indicative of deficiency of biliary secretion, or a
diversion of the fluid upwards, in consequence of puking, or, as may hap-
pen, some form of the intestinal fluxes prevails.

Concomitant on one of these conditions, or immediately succeeding to
it, there is pain in the right hypochondrium, sometimes pungent, and in other
instances dull, with feelings of fulness and weight — and on pressure, or from
a deep inspiration or cough, an increased sensibility is betrayed.

The pain sometimes extends to the right clavicle, or to the top of the
shoulder blade, and I have known it to be felt exclusively, and often more
acutely there, than even in the region of the liver.

Cases, however, occur, and especially in women, where all the sufferings
of the primary as well as the secondary affection, is in the opposite side, and
here, probably the seat of the lesion is in the left lobe of the liver.

Commonly, the fever becomes high, with a strong, full, disturbed pulse, hot
dry surface, foul coated tongue, bitter taste, much thirst and headache — and after
a few days, the skin may be tinged of a dusky or bilious hue, in which latter
the adnata participate, — and the urine, which is much reduced in quantity, is
of the various shades of yellow to a deep saffron.

The liver is now sometimes so swollen, and tender, that the patient can
lie on neither side, though he is most disposed to turn on that affected, as
the least uncomfortable, being thereby relieved, in a degree, from the weight
and oppression of the distended organ. Tenderness occasionally pervades

348

Monograph.

the whole abdomen, owing, to the extension of tlie inflammation, from the
peritoneal covering of the liver, to that membrane generally. But I have seen
hepatitis where there was no pain in the affected part, or at the shoulder, no
sallowness of the cutaneous surface, or of the eyes, and very little aber-
ration in the pulse. Greatly is the disease diversified by climate, and very
prone is it to exhibit irregular and anomalous symptoms. Especially in In-
dia, its onset is sudden, sometimes without any premonition, and its course
much more rapid and vehement, running to suppuration in a few days, and
in some instances, without any distinct expression by pain or fever. The
action is said to be rather congestive, with a mixture of inflammation, than
actually inflammatory.

Nor is it uncommon for an attack to be ushered in and associated
throughout, with the phenomena of diarrhoea, dysentery, or cholera morbus.
Cases of the disease have also come under my notice, assuming the guise of
gastritis, or to expend their force entirely on the head, producing the most
relentless agony, with great mental disorder, or in the kidney, or at the
umbilicus, or in the calf of the leg, with a numbness of one or both arms.

Cullen, and indeed most writers, have endeavoured to explain some of
these deviations from the common order in the phenomena, on the suppo-
sition, that in such cases, different portions of the liver are affected.

Thus it is affirmed, that when there is a predominance of pectoral symp-
toms, the convex surface is inflamed — and conversely, if much gastric
uneasiness prevails, the concave. It is also alleged, that the disease is
modified, as the membranes, or parenchyma of the organ may be the seat
of the affection. No d )ubt such is the fact. The peritoneal covering or
ligaments being phlogosed, we shall have sharp, acute, lancinating pain,
with a hard, corded, small pulse, and a white furred tongue, without the
sallow hue, or vitiation of the biliary secretion — and very much the con-
trary, when the substance is phlogosed, or dull, obtuse sensations, with a
fuller and slower circulation, — a brown or yellow, and more heavily loaded
tongue, and an excess, or suppression or depravation of bile. But in most
instances, each structure is involved, so that the phenomena become con-
founded. It is questionable, indeed, whether distinct inflammation of the
peritoneal covering or its ligaments, ought to be considered as hepatitis.
More properly it appertains to peritonitis.

An acute phlogosis of the liver itself is, for the most part, and always
when intense, rapid in its progress, and if a decided impression be not made
on the case, we shall perceive in a few days, either a sinking of the vital
forces, or the signs of suppuration taking place, or a tendency to chronic
degenerations.

Men, it is said, are much more liable to the disease, than women — and
that it rarely shows itself in children.

The latter remark, however, is not of universal application. Children in
miasmatic countries, are singularly subject to it, especially in the subacute,
or chronic shape — and I suspect, that the greater number of cases among
men, under ordinary circumstances, is referrible only to their depraved
drunken habits, or greater exposure to its other or external causes.

Causes. — In common with the phlegmasia, hepatitis may be excited by the
sudden vicissitudes of weather, cold succeeding to heat especially, or by mecha-
nical injuries, as blows, falls, <fcc. Not an uncommon cause is the abuse of
ardent liquors, or excess in eating, particularly of high seasoned or gross food.
The former is insisted on, while the latter, is too generally overlooked.

Detrimental as intemperance in drink undoubtedly is, in this and other
respects, I presume that our well being is not less affected by gluttony, and

349

Chapman on Diseases of the Liver,

that the good of society as much requires an institution for the reformation
of the gourmand, as tlie drunkard. The inconsistency of mankind, some-
times very extraordinary, has rarely been more strikingly illustrated, than in
this very instance. It might be instructive to listen to the denunciations of
our modern moralists against whiskey potations in particular, were they
not so often accompanied by the belchings of the fumes of ill digested turtle,
or of luncheons of roast beef.

As to hepatic obstructions, I am quite sure, that such a course of living is
a most prolific source. By Sliakspeare, the closest of observers, we are
told:

“ It engenders choler^ planteth anger.

And better ’twere, that both of us did fast^
Since of ourselves, ourselves are cholerick,
Than feed it with such overroasted stuff.”

Temperance, I repeat, consists in moderation as well in eating as drinking,
and he who wislies to preserve health or decency must alike restrain the
“ lusts of appetite,” in each respect.

Milton has truly said:

“ If thou well observe

In what thou eaVst and drin¥st, seek from thence
Due nourishment, not gluttonous delight.

Till many years over thy head return;

So may’st thou live, till like ripe fruit thou drop
Into thy mother^s lap, or be with ease
Gather’d not harshly pluck’d for death mature.”

But of the physicial agencies, perhaps the most operative are heat and
miasmata. That the former alone, produces the disease, I am aware has
been disputed. Not to repeat, what has been so often discussed, the influ-
ence of a high temperature in deranging the chylopoietic viscera, I have now
only to state a fact of the effects of heat on the liver. The “ pate de fois
gras,” so delicious to the epicure, is made chiefly of the liver of geese.
It is well known, that at Strasburg on the Rhine, where this celebrated pie
is prepared, the practice exists, with a view of giving a preternatural growth
or hypertrophy to the liver, of placing a goose for some hours before a fire,
and that even within so short a time, this organ is enormously swollen in its
dimensions. As cold deranges the pulmonary, so does heat the hepatic
apparatus, and each state of temperature is similarly distinguished by the
variety of morbid conditions into which it respectively throws these organs.

Combined with miasmata the operation of heat is still more powerful, so
much so indeed, that the disease is often endemic in such an exposure. We
have examples of it in onr own country, and still more strikingly along the
coast of Coromandel, and in the alluvial districts of Bengal.

Nearly as much are brute animals liable to it in such situations, and par-
ticularly cattle and horses. Born under the morbid influence, they as the
human species are less affected by it, though neither has an entire immunity.
By some of the oriental writers, it is stated that animals in common with
man, brought from Europe, speedily fall victims to it in large numbers, and
I am told, it is equally so in relation to our southern states. Exactly the
opposite holds as to pulmonary affections, or the natives of the warm,
the human and the brute, suffering in this way, on a translation to a cold
region.

In medium climates, hepatitis is seen chiefly in sporadic occurrences, and
in its mildest presentations. As to this city and vicinity, I know this to be
No. XLVIIL — August, 1839. 30

850

Monograph.

true, and have reason to believe it to be the case in western Europe. But
on some occasions it is otherwise, and hepatitis breaks out, and spreads
extensively and violently. An instance of this kind happened in Ireland
in 1818, where it previously had sparsely existed, the disease very frequent-
ly ending in abscess, such was the force of its character — and with us,
during the existence of the epidemic constitutions, causing yellow and
intermittent fever, the same was observed both as to the human species and
animals, cattle and horses especially suffering, with what was called the
yellow water, I presume from the urine having that colour, a febrile affection
occasionally terminating in suppuration of the liver.

Certain mental emotions may also be included among the causes of the
disease in the human subject. Exasperated anger, or terror, or jealousy,
irritate and distend the liver, promotive of an increased secretion — while
fear, or grief, or other depressing states, have an opposite effect.

The ancients were aware of the influence of jealousy, and its corres-
pondent irritability and fracliousness on this organ.

Does not every classical scholar remember the beautiful lines of Horace,
that Prince of Poets?

“Cum tu, Lydia, Telephi
Cervicem roseam, et cerea Telephi
Laudas bracliia, vae, meum,

Fervens difficili bile tumet jecur.'*^

Even temper and character have such an influence on the organ, that to
call the sour, the envious, and malignant, a white-livered fellow, has grown
into a common phrase.

No less remarkable is it, that most of the complaints of the lungs, cheer
and preserve the spirits while those of the liver induce dejection, gloom,
and melancholy.

The very term hypochondriasis^ is derived from the notion of antiquity,
that it depended on some affection of the hypochondriac regions, and melan-
choly, from the Greek, signifying black bile. Between the brain and the
liver, there would seem indeed, to be as close a physical as moral sympa-
thy. We know, indeed, how much the former shares in all the diseases of
the latter, and which is fully reciprocated. Concussions and other injuries
of the brain have often been followed by suppuration of the liver, and con-
versely, lesions of the liver reflected on the brain. By the metastasis of
gout, and still more frequently from the suppression of haemorrhoids, though
neither event is very common, this disease is occasioned.

Diagnosis. — No very great difficulty is there usually in the recognition of
acute hepatitis.

The case with which it might be supposed most readily to be confounded,
especially when the left lobe of the liver is affected, is splenitis. But this
is of such rare occurrence, that even its very existence has been doubted, and
fof which I, at least, have never seen an instance.

Gastritis might, in the commencement, be more readily mistaken for in-
flamed liver, so greatly is the stomach irritated and disturbed occasionally.
But after a while, the morbid action becoming more concentrated in the
former organ, the phenomena are less confused or ambiguous. Equally
may phlogosis of that portion of the colon approximating the liver be con-
founded with hepatitis. Yet by a careful examination, they are to be dis-
criminated, and among the signs none perhaps, is entitled to greater confi>^
dence, than the imperfection of the process of fecation, when the intestine is
concerned.

Chapman on Diseases of the Liver, 351

"J'his disease is sometimes imitated by pneumonia. An accurate compa-
rison, however, of the phenomena of the two complaints, will generally
dissipate the obscurity. Even the pain, the cough, and impeded respira-
tion, the symptoms which cause the perplexity in these cases, are not simi-
lar in all respects. They are in hepatitis, less prominently marked, and
seem rather the result of secondary, than primary irritation of the lungs,
and at the same time, we have indirect impression of hepatic disturbance, the
gastric distress, the tenderness on pressure, with the peculiar appearance of
the skin, and of the alvine and urinary discharges. No implicit reliance can
be placed on the pain of the shoulder, to which such importance is generally
attached. It is very frequently wanting, and when it does occur, is said by
Louis to be more indicative of pulmonary than hepatic disorder, in which
opinion, I do not concur. But, in the external means of exploration, per-
cussion and auscultation, there is always a key to unlock the chest and ex-
pose it, as it were, to view. It may be further remarked, as strongly denoting
hepatitis, that soon after the blood is drawn, or prior to its coagulation, it is
of a dull green color, and on the separation of its constituent parts, the sur-
face formed of the size or lymph more particularly, is yellow.

Prognosis. — An attack of acute hepatitis, ending favourably, or by reso-
lution, is often distinguished by some critical discliarge, as copious haemor-
rhage from the nasal or haeraorrhoidal vessels, or profuse perspiration, or
urinary, or alvine evacuations, or by erysipelas, the internal irritation being
thus reflected on the cutaneous surface. Nature, however, not relieving
herself in any of these modes, approaching convalescence is evinced by
subsidence of fever, and topical pain, by tranquillity of the stomach, less
constipation, and more bilious stools, with improvement of complexion.

An opposite conclusion is warranted, wJien such happy changes do
not take place. Of the adverse terminations, one of the most common is in
suppuration, and an abscess being formed, its contents may be variously
evacuated. To have the matter pass out through the ducts is the most de-
sirable, and next to this, externally. The abscess usually points over the
region of the liver, though in one case it broke in the axilla.

As liable, however, is it to rupture inwardly, and here, unless the matter
is thrown into the primae vise, the event is usually fatal. Most frequently it
is emptied into the colon, though sometimes into one of the small intestines,
or the stomach. Examples are recorded, where it opened into the abdomi-
nal cavity, proving mortal by inducing peritoneal inflammation or hectic
fever. But such a catastrophe does not uniformly happen, we having in-
stances where the fluid being absorbed, the event was favourable.

It is said to have burst into the thorax, the pus expectorated, and a final
recovery, though, more commonly, suffocation has speedily followed such
occurrences. Thirty years ago. Dr. Pascalis, of New York, then residing
in this city, was supposed to have survived under these circumstances, and
similar instances are related by Annesley and other writers.’^ But conclusions
of this kind can only be conjectural, where no subsequent opportunity pre-
sents of an autopsic inspection. Expectoration of purulent matter does not
afford positive evidence of the rupture of an hepatic abscess into the chest.

By sympathy, the mucous tissue of the lungs becomes phlogosed,
and secretes pus. Formeidy, a case of this kind occurred in our hospital,
which, at the time, was thought very anomalous and perplexing. The
patient died, having previously, for some weeks, expectorated pus freely, as

* See this Journnl for Nov. 1837, p. 253, and for May 3838, p. 176.

352

Monograph

was presumed, from an abscess of the liver communicaling with the thorax.
None, however, or even any adhesion, was discovered on dissection.

In a second instance of supposed hepatitis, the pus escaped wiili the urine,
and, on examination after death, an abscess of the kidney was detected, the
liver being perfectly sound.

Clarke mentions a case in which the matter escaped into the pericardium,
and another of similar description is given by Smith of this country, to wliich
a third has lately been added by Professor Graves, where the abscess com-
municated with both the pericardium and stomach — all three, of course,
proving fatal.

From what has been said, much may be collected of the curability of this
disease. Nearly always, with us, when timely and vigorously treated, it
submits to our remedial processes. But under different circumstances, it
proves otherwise very generally, by suppuration, or other organic lesions,
which, sooner or later, terminate or embitter existence by the sequelae en-
tailed.

Louis says, that recoveries never happen where an abscess forms. Nu-
merous as his examinations were, he met with no instance of cicatrization,
or a tendency to it. But such negative testimony must not be received as
conclusive, against the positive experience of many respectable authorities.
Two instances of recovery I have known myself.

Lesions. — On a post mortem inspection, we find the liver more or less en-
larged, and in those instances, where the serous covering is implicated, marks
of phlogosis, which consist mostly of extravasations of lymph, less adhesive
than usually, and with little disposition to become membranous, or to form
attachments. Externally, the liver itself is of a livid, red, or marbled aspect,
and what is observed on dissection of it, may, perhaps, be embraced under
the several states of increased vascularity, softening of texture, suppuration,
and gangrene. Commonly, the lesions are on the surface, though often also
in the very substance of the viscus. Each portion may be independently
affected, or both unitedly.

Death taking place in the early stage, the vessels are turgid with blood,
productive of redness and swelling of the organ; Connected with these, in
the second stage, the substance is brittle or friable, and being squeezed be-
tween the fingers, seems to be granular, though readily reduced to a pulp- —
and such is sometimes the ramollescence, that it is almost deliquescent. When
the case is still further advanced, the texture is changed from a reddish to a
yellowish hue, by the presence of pus, which gives to it this colouration.
The purulent matter is diffused through the cellular structure, or collected in
several small, or one large, or even enormous abscess. But instead of pus,
it may be a heterogeneous fluid of a dark grayish colour, or resembling the
washings of flesh, with flakes of blood in it. Genuine purulent abscesses are
seldom met with in the temperate climates of Europe, or in this city. I.ouis
states, that in four hundred and thirty dissections, he detected only five in
the substance, and not one in the coverings — and suspects that the latter
occurring, it is in the cellular membrane, between the peritoneal investment
and the glandular structure of the organ.

Bichat asserts, that gangrene of the liver may take place, and which,
though rarely, has been subsequently observed by Andral, &c. Never have
I seen it, or heard of its being seen, in our investigations in this city in pri-
vate or public practice. No one, perhaps, has liad greater advantages than
Annesely, in determining this point, from his long residence in India, the
region most prolific of the disease, and from the ardour with which he seems

Chapman on Diseases of the Liver.

353

to liave cultivated its pathological anatomy. But he, never meeting with
it, is disposed to infer, that what has been apprehended to be gangrene, was
the black congested and softened stale of the viscus, incident to very violent
attacks of the disease, or to a putrid condition induced afier death, which
conjectures I think very probable, as such appearances I have witnessed
from each of the causes he. alleges.

Besides the phenomena already noticed, it is not uncommon to remark
inflammation, with other lesions, of the mucous lining of the gall bladder,
and of the biliary ducts; frequently, also, of the stomach and the duode-
num, and in some rare instances of the entire track of the alimentary tube,
as well as of the peritoneum and other portions of the abdominal viscera.
Nor does the brain, especially where much cerebral disturbance has pre-
vailed, escape — it betraying, on the contrary, sometimes, all the manifestations
of extreme sufferings.

Pathology. — Excepting the peritoneal covering, or ligaments are primarily
engaged, where it may be otherwise, I believe, that in common with every other
real hepatic affection, an inflammation of the liver, not occasioned by some di-
rect act of violence, has its original seat in the stomach. An irritation is first
given to the mucous surface of that viscus, and continuously, or by consent of
parts, becomes extended to the duodenum, ductus choledochus, and finally,
into the more intimate structure of that organ. These pathological views,
having fully developed on a preceding occasion, I shall not again expatiate
on the subject. Enough may it be for the present to stale, that I am led to
this conclusion by the history of the causes, their nature and mode of opera-
tion, the early symptorxiS, and appearances on dissection in hepatitis, when
it terminates suddenly, and from its close analogy to the affections, which
are undoubtedly of gastric origin. Many instances indeed of it come on in
the form of gastritis, or diarrhoea, or dysentery, showing clearly that the
liver is not here, at least, the seat of the first link in the chain of the morbid
process. No pathological fact is better established, than that an irritation at
the mouth of any duct, is speedily transnntted throughout its ramifications,
with a tendency to involve all structures with which it may be connected.

An effect of this hepatic irritation, is a fluxionary movement, pro-
ductive of more or less congestion of the portal circulation, by which the
liver is distended and enlarged, followed usually by inflammation, with some-
times, ultimately, those diverse disorganizations incident to the case. From
a concentration, however, of the morbid action in the liver, the original, or
initiatory disturbance of the primse viae, is often relieved or becomes so sub-
ordinate as to be concealed or masked in many cases, though it may be
different, or the whole series of affections from the first to the last, uninter-
ruptedly maintained, and conspicuously exhibited. This is essentially the
doctrine of Broussais, in which, however, he was anticipated by me, by
many years.

Treatment. — The treatment of acute hepatitis is now generally understood,
and pretty well defined. We have a case of active inflammation in a voluminous
and important organ, which can only be arrested by prompt, vigorous, and de-
cisive measures. Of these, incomparably the most effectual is venesection.
Not to be dispensed with in any severe parenchymatous phlogosis, it is here
peculiarly serviceable from the intimate connection of the organ with the
venous circulation. The lancet, in many instances, is to be freely urged,
and the operation to be repeated day after day, in vehement forms of the
disease. Nor am I aware that in cases of a more congestive character, vene-?
section should not be carried to the same extent. As vindicating the practice^

354

Monograph.

it may be slated, that on the loss of blood in either state, a most manifest
subsidence of swelling and tenderness of the liver takes place, with a corres-
pondent general improvement of condition.

Much may also be expected from topical bleeding, by cups or leeches,
which, however, is more especially useful where the pain is acute, and
dependent on inflammation of the coverings of the organ. It is customary
to apply the leeches over the seat of the affection, and here they answer very
well. But some of the recent writers insist that they prove still more efficient,
when put around the anus. Considering the greater intimacy of connection
of the vessels of this part, with the portal circulation, it is not improbable,
and which indeed is confirmed by the decisive results of the hemorrhoidal
flux in such cases. But then to prove so efficacious, the phlogosis or con-
gestion must be sealed chiefly in the substance of the liver.

Emollient cataplasms, or fomentations in any way to the affected side, are
SQmetimes productive of great relief.

On adequate reduction of vascular excitement, the application of blisters
becomes highly important.

Nevertheless, while using the lancet, and its immediate auxiliaries, we
must not neglect some other means. It is confessed, on all hands, that where
the stomach or intestines are not actively inflamed, purging is immensely ser-
viceable. Cahmiel is the proper article, exhibited at night in a large dose,
and worked off the next morning with Epsom salts or castor oil. 'J’o purge
freely in this case, is of peculiar importance. The liver, while phlogosed,
has also its secretory function suspended or impaired, and, though the former
stale may be subdued by the loss of blood, the cure will not be accomplished
till the latter is restored. It has been justly remarked by Johnson, that the
liver under such circumstances is like the female breast gorged with blood
and stagnant milk, and unless the lactiferous ducts are emptied of their con-
tents, suppuration will ensue, in spite of general or local bleeding and other
means. Exactly so witli regard to hepatitis. The biliary ducts must be
emptied of the viscid and vitiated bile, by which they are obstructed, and the
healthy secretion reinstated, or suppuration, or chronic disorganization, will
take place. Now, to meet this indication, calomel, above all articles, is
appropriate, it emulging the liver, and promoting its natural offices. Though
many other purgatives will evacuate the bowels, it is the mercurial prepa-
rations only, that thus operate efficiently on the hepatic apparatus. Con-
curring in the design of subduing the febrile state, the antimonials, or the
nitrate of potash, alone or combined, the neutral mixture, or any other mild
febrifuge, may be usefully interposed.

Next, salivation is usually endeavoured. It has, however, been made a
question by some, whether we should resort to it at the onset, or wait for
the reduction of the phlogistic condition. But in my opinion, there can be
no doubt of the preference of the latter course. To do otherwise, w ould in-
deed be, for the most part, nugatory— since, while there is much vascular
excitement, mercury will rarely act, and, if it succeed, it only has the effect
of exasperation, by the irritation it induces, preventive of the resolution of
the phlogosis. Yet in India, pretty generally, and occasionally in our own
climate, an opposite practice is pursued. 'J'he expediency of salivation,
under any circumstances, or at any stage of acute hepatitis, is very doubtful
with me. Nor is this view peculiar to myself. By a late writer of great
authority on the diseases of India, the following language is held. He says,
“I am anxious in the acute affections of the biliary organs, to avoid the con-
stitutional effects of Calomel, because, 1 believe, that when these are pro-

353

Chapman on Diseases of the Liver,

duce(], the energies, and vital resistance of the system are thereby impaired,
and the presence of this mineral in the circulation tends to keep up in the
inflamed part, a degree of excitement and irritative action, which would
otherwise subside, and which 1 am persuaded tends in many instances, when
allowed to proceed, to occasion chronic derangements of the viscus, and even
abscesses, if the inflammation be seated in the glandular structure of the
organ.*” Conformably to my own experience, it is far better in every
respect, at this period of the case, so to manage mercury, as to attain its
alterative, or revolutionary effect on the secretory functions, and which is to
be done by small doses of calomel, or the blue pill, with opium and ipeca-
cuanha, occasionally resorting to a mild laxative.

No plan of cure, however, will uniformly succeed — and, in defiance of our
exertions, suppuration may ensue. Yet this event, though common in the
intertropical and other very hot regions, is rare in temperate climates, and
with us, may almost invariably be traced to negligent, inadequate, or no
treatment at all, among the poor and vicious classes of society, 'I’he suppu-
rative process is usually denoted in its approach, by an increase of pain, and
sense of weight, and enlargement in the affected part — by a full, hard and
active pulse, and the indications generally of more violent excitement. -

Being completed, or in other words, the abscess existing, there is a remis-
sion of pain, or rather, it is exchanged for a dull, obtuse, sensation, or, as
occasionally happens, throbbings, or pulsating sensations, and, at the same
time, there are rigors, with irregular exacerbations of fever, attended by
flushes of the fiice and nocturnal sweats. Three heteroclyte symptoms, now
and then occur, in this state of the disease. These are, a feeling of formica-
tion throughout the skin, an inability to sneeze, even when the strongest
sternutatories are applied, and numbness, or loss of motion in one, or both
of the lower extremities.

Even in the suppurative stage of the complaint, mercury has been recom-
mended, without, however, any advantage. It is a fact, not generally
known, though I have seen it abundantly verified, that mercury will hardly
operate specifically in any disease, during the suppurative process, and which
is strikingly exemplified in venereal buboes, where it exercises not the
slightest influence. 'I’he two actions are incompatible, or that of the remedy
is too feeble to overcome the morbid one.

An abscess may take such a direction inwardly, as not to be recognised.
But pointing externally, so as to be perceptible, it should be matured by
poultices, and then punctured. Cures, when the matter is thus let out,
often follow, and very seldom, if it be permitted spontaneously to dis-
charge. This is in conformity especially with the observations of the
East India writers, and, perhaps, is readily explicable. By timely evacu-
ating the contents, disorganisation is arrested, which otherwise becomes irre-
parably extreme.

From an indisposition to adhesion between the liver and parietes of the
abdomen, the operation, however, is alleged to be not always safe, as an
escape of the fluid into the peritoneal cavity may take place, and hence it is
deemed prudent, previously to performing it, to endeavour to secure such
adhesion. The expedient, hitherto adopted with this view, has been the
establishment of a caustic issue over the affected part, which having
failed in several instances, and death consequently resulting, is now
much distrusted. It is proposed, as an efficient substitute, to make

Anncsley, p. 424.

356

Monograph,

an incision at the most prominent point, down to the peritoneum, keep-
ing open the wound by pledgets of lint, and I have heard of some in-
stances of its complete success. But though suggesting this new expedient
in the case, it may be right to mention, that I have myself, or seen others
operate in several instances, without regard to it, and no detriment accrued,
the adhesion being perfect.

The abscess having been emptied in any way, or, indeed, while the mat-
ter remains, there is usually much debility and irritation, and the system is
to be soothed by opiates, and sustained by a cordial, though mild diet, with
the aid of tonics, particularly the nitric, or nitro-muriatic acid, which under
such circumstances, may prove highly serviceable.

Need it be remarked, that during the inflammatory stage, the regimen ought
to be strictly antiphlogistic, to be continued in the convalescence, and for a
considerable time afterwards, with very little change, and, to prevent a
relapse, the patient, when practicable, should remove from a miasmatic dis-
trict, and forever abstain from gross, or stimulating food, and above all, alco-
holic liquors.

II. Chronic Hepatitis. It has hitherto been the custom, from the vague-
ness of [information on the subject, to include under this denomination,
nearly every protracted lesion of the liver. Granting, that most of these
afleclions originate from, or acquire inflammation in their progress, it is no
less true, that others are independent of it, throughout all their stages, and
hence, differing totally from them, in their pathology, and treatment. Even
as to the former cases, the term chronic, as importing tluration only, very
imperfectly expresses the real condition, which is mostly that of subacute
inflammation.

But a name is not of much consequence, when the sense is well defined,
and may be adopted, or retained conventionally.

Cullen would teach us to believe, that the difference in the twm cases is
owing to the investing tunic of the liver being phlogosed in the acute, and
the parenchyma, in the chronic state of the disease. But the explanation is
utterly unsatisfactory, and has been accordingly long abandoned.

The fact is that, under such circumstances, we should have two distinct
pathological conditions, the one an inflammation of the serous, and the other
of the cellular tissue of which the parenchyma consists. But, as previously
remarked, it is only the last that properly can be considered as hepatitis, the
former being peritonitis. An hypothesis equally absurd has been advanced
by Saunders, who supposes in the first, the system of the hepatic artery is
concerned, and in the second, that of the vena portarum.

Symptoms. — Chronic hepatitis is so diversified in its aspects, that it is not
-easy to delineate it, in any general descrij)iion. Taken, however, in its most
common presentation, there is considerable local pain, usually obtuse, though
occasionally exasperated into intense agony, sometimes attended by the sym-
pathetic ache about the clavicle, or scapula. Mostly, the weight of the
liver is sensibly felt, and by pressure on the diaphragm may excite
cough, or create embarrassed respiration. With these topical affections, we
have an assemblage of phenomena indicative of general or constitutional dis-
turbance, such as inveierately dry skin, of a dusky or icterose hue — often
much depravation of the stomach, attended by a sense of fulness, costive
bowels, and the stools clay, or state coloured, inodorous, or very offensive
— scanty dark urine, sometimes depositing a pink or lateritious sediment, or
it is only turbid, from a mixture of mucosity, the whole accompanied by

357

. Chapman on Diseases of the Liver.

more or less fever — the pulse being quick, firm and corded, or, as some-
times happens, is intermittent, and otherwise irregular, from a loss in the
balance of the circulation, by the impeded movements of the blood through
the infarcted liver. Consequent on this state, haemorrhage is apt to occur
from the liver itself — or the blood being otherwise determined, from the
spleen, stomach, intestines, the lungs, and particularly from the nasal or
haemorrhoidal vessels. In the progress of the case, the bowels become
harassed by tormina or flatulence, or colliquative diarrhoea ensues, the dis-
charges being dark, or light coloured, slimy, or watery, or muddy, and very
foetid. Emaciation, henceforward, rapidly takes place, with oedema of the
lower extremities, which with other effusions, leading to general dropsy, is
one of the modes in which the disease very frequently terminates.

The development of the disease, however, may be slower or less percep-
tible, so as to continue for months, or even years, without any manifestation
of its existence, save a sense of fulness after meals with flatulence, sour eruc-
tations, palpitations, drowsiness, a disinclination to exertion, costiveness,
depraved secretions, restlessness, ami disturbed sleep, resembling, in the
whole, original dyspepsia, for which it is usually mistaken, till the symp-
toms of hepatic affection are more unequivocally disclosed. Blended with
this dyspeptic state, or independent of it, there may be in the advanced stage
another train of secondary aflections, as dry cough, or asthma, or other pul-
monary lesions, or in other instances, a tremendous headach supervenes,
recurring periodically, often eventuating, in children especially, in hydroce-
phalus, and, in more advanced life, in apoplexy or palsy. These are some
of the ordinary aspects of the disease, which, however, are so infinitely
varied, that it were impracticable, within any narrow limits, to delineate
one half of its modifications.

Linked most intimately with nearly every part of the system, the liver,
through the medium of its sympathies, either actually deranges them or
simulates their affections. Extensive, too, as are these physical sufferings,
our moral constitution is not permitted to escape. Even mania has been some-
times the result, and, still oftener, the deepest melancholy. Generally, how-
ever, the mind is gloomy, petulant, morose, despondent, the real being
aggravated by fictitious afflictions, and in this reciprocal play of mind and
body, a state may be induced, of which the vulture feeding on the liver of
Prometheus is no exaggerated image!

Causes. — On the origin of chronic hepatitis, I have to remark that it is
frequently the acute disease abated, though not cured, running into degene-
rations, or a primary condition of the same kind may be brought on by the
slow and feeble impression of the causes already enumerated, as well, per-
ha[)s, as by some further agencies.

Combined heat and miasmata, however, are considered the most produc-
tive of the causes, and which may be so in certain regions, sometimes in-
ducing the disease directly, though ofiener entailing it as one of the sequelae
of autumnal fever, particularly the intermittent form of it. But drunkenness
is, perhaps, little less influential among the vulgar in some sections of our
country, and much may be ascribed to indolent, sedentary and voluptuous
habits — in the higher classes of society, particularly in regard to eating.
With the Romans, in the advanced and degenerate ages of the empire, the
liver of geese became a choice luxury, ami, to give it an enormous growth,
the animal was nailed through its feet to one position, and crammed with
food. What was thus effected in the goose is unintentionally brought about
in the lazy and gluttonous geese of the human family!! 'iflie same result

358 ' Monograph,

takes place in cattle, hogs, and other animals, by high feeding in close con-
finement— they becoming what is called grown'' Known to our

farmers generally, the fact has been lately corroborated to me by the butchers
of this city.

Nor can I help thinking, and on no slender grounds, that the extravagant
use of mercury by many of our practitioners, in the treatment of autumnal
fevers and other diseases, must also be assigned as a frequent cause of the
chronic hepatic affections in some portions of the United States. More than
any other article of the Materia Medica, at least, has it the power of exciting
the actions of the liver, and it is a law of our nature, that all high excitement
is followed by a correspondent degree of debility. From the circumstance
of the prodigious employment of calomel in the cases to which I have alluded,
amounting to several drachms daily, it seems to be no unreasonable supposi-
tion, that the hepatic apparatus, thus over-stimulated, should fall into collapse,
and, in this condition of exhaustion, torpor to take place in the portal circu-
lation, productive of congestion, eventuating in phlogosis, induration and other
derangements. Doubtless in this mode do miasmata and high temperature,
separately or unitedly, and the habitual consumption of ardent spirits operate
to the same effect. As confirmatory of this view, it is stated, by Dr. Somer-
vail, a most respectable physician, of the South of Virginia, who has prac-
tised medicine for nearly half a century in that section of the country, that
till the introduction of mercury, a comparatively modern event there into the
treatment of autumnal diseases, hepatitis was hardly known, and, subse-
quently, it has most widely prevailed. We have also seen, that it is the
opinion of Annesley, whose opportunities of witnessing the effect were so
ample, that the large use of mercury in the inflammatory stage of acute
hepatitis, by an increase of excitement, has a tendency to induce chronic
degenerations. That it occasions jaundice, most probably, by deranging the
liver, will hereafter appear, as well on the authority of some cases which
several years ago occurred to myself, as others, more recently reported, by
highly respectable European writers, in support of the conclusion.

Be this however as it may, there can be no question whatever, that a very
bad practice, in another respect, is a common cause of the disease. My
allusion is to the premature and indiscriminate resort to stimulants and tonics,
to the neglect of sufficient evacuations in our fevers — an evil which has
immensely increased since the terror of typhus pervaded the nation. The
abuse or misapplication of bark, wine, and ardent spirits, as remedies, I do
believe has obstructed nearly as many livers and spleens as all the miasmata
and heat of our climate.

Diagnosis. — Carefully traced, the symptoms I have detailed will, for the most
part, satisfy us of the existence of chronic hepatitis, and, as regards enlargement
and induration of the liver, all doubt may be removed by an actual examina-
tion, which is done by laying the patient on his back, his head low, and his
knees drawn up, so as to relax the abdominal muscles, and simultaneously
directing him to take a deep breath, to protrude the liver. But this organ
may be much diseased without any enlargement, and even preternaturally
diminished, so as not to be reached by any examination. Even the tactus
eruditus wdll, in this application of it, fail. Nevertheless, there is one cir-
cumstance, without implicitly relying on it, which, I think, is entitled to
great confidence. In every case of atrophy of the liver I have inspected, it
had been marked during life by extraordinary palor of skin, even of pearly
whiteness, or more of the hue of dingy while wax, exhibiting altogether an
extreme exsanguineous condition and aspect. That an extreme penury of red

359

Chapman on Diseases of the Liver.

blood, the latter supplying the nutriment of organs, should lead to such an
effect, is plausible in itself, though it is not so obvious why it is displayed
more conspicuously in the liver. Yet peculiarities may be traced in the
economy of that viscus, which might be made, perhaps, to account for the
phenomenon.

Nor is the preceding the only source of perplexity. As incident to the
liver as perhaps any organ, is a painful condition, entirely independent of
phlogosis, w'hich, from the analogy of some of the symptoms, might be mis-
apprehended. It has hitherto been called hepatalgia, under which term is
embraced nearly every liver pain^ on whatever state it might depend, as the
irritation or spasm, of biliary calculi, &c. Caused in any of these modes,
there is little difficulty of discrimination, and, passing them over, 1 shall con-
fine my remarks to an affection purely a neuralgia or nerve ache. Even,
however, as to this pathological condition of the nerves, it may suffice, at
present, to state that its prominent and peculiar features are the acuteness,
the darting, fluctuating, and periodical nature of the pain, with the absence
of fever, and other material hepatic or constitutional disturbance, in all which
particulars differing from chronic hepatitis.

Diseases of other parts, however, may be mistaken for this of the liver.
Chronic gastro-duodenitis, as well as the lingering inflammations of the colon,
are of this description. Many of the cases of supposed hepatitis, on which
I am consulted, turn out on examination to be intestinal lesions, and particu-
larly of the arch of the colon, which latter indeed, 1 am inclined to suspect
are far more common in every portion of our country than those of the liver.
These lesions have, to some extent, a commonalty of symptoms, and hence
the obscurity of the diagnosis. There may be pain in the right hypochon-
driac, sallow complexion, much gastric disorder, hectic irritation, and great
vitiation of the alvine, as well as the urinary discharges, in the whole of
which, resembling chronic hepatitis.

Called on here to pronounce the most certain criterion, I should say it may
be found in the character of the stools — those in hepatitis generally indicating
the absence of bile, while the evacuations in colonitis as uniformly betray
the loss of the faculty of faecation. This discriminating sign is, however, some-
times fallacious. The liver though much diseased, may be sufficiently sound
in a part to secrete bile, and the colon so partially affected, as to elabo-
rate some faeces. 'I’o show the difficulty of the diagnosis, I will mention a
case. It was that of a man brought into the Alms House Infirmary, with nearly
every symptom of chronic hepatitis. He had previously been treated for
such, by one of our best physicians, who, supposing an abscess of the liver,
pointing externally, punctured it, and let out about three pints of pus. The
man dying soon after his admission, we found, on opening him, that the
arch of the colon, in the right hypochondrium, had adhered to the parietes
of the abdomen, forming a large sac, filled with pus, the liver being perfectly
healthy.

Prognosis — Not more can be affirmed, with certainty, in regard to the
prognosis, than that a considerable portion of these cases is curable, though
only when the lesions are slight, and of no very long existence. Extensive,
and confirmed injuries of structure are irremediable. Yet it often happens,
that life is indefinitely protracted, where the liver is greatly affected, owing
to a part of it remaining sound, and adequately performing the function of
the secretion of bile.

Lesions. — 'Phe liver is found on a post-mortem examination, generally of a
gray, or ashy hue, and altered in shape and dimensions, as well as texture,
sometimes prodigiously enlarged, or conversely, wasted to a very diminutive

360 Monograph.

size, preternaturally hard or soft, tuberculaled or interspersed with a collec-
tion of small abscesses, or one or two large ones, llie latter among ns, more
common in the chronic than acute disease, the fluid contained being purulent
or sanious, or of a caseous nature, or in place of abscesses the substance of the
viscus converted into a cheesy, slealomatous, tallowy, cartilaginous, or osseous
matter, or now and then, studded with hydatids. Examples of ulceration, even
cancerous, occur, and in one instance at least, the whole of the parenchyma was
removed by its ravages, leaving only the vessels, resembling a corroded prepa-
ration of the organ, as in the case of the celebrated Sir William Jones, who
died in Bengal. An occasional event, is that of an extraordinary growth of
the liver, without any niateidal change in its structure, constituting a mere hy-
pertrophy. The most remarkable instance, perhaps, of this kind on record,
is one where the liver weighed forty pounds. But with enormous develop-
ments, it is generally diseased. We are told by Johnson, that he has seen
it “ of all sizes, and extending from the margin of the ribs, to various depths
of the abdomen as far down as the pubes.” Gooch gives a case where it
weighed twenty-eight potinds — Baldinger another of twenty pounds — Bovet
a third of eighteen pounds — and Mr. Abernethey one, which filled the whole
cavity of the abdomen, without, however, his slating its weight. In several
instances, I have seen it myself, of a very great size, though always much
disorganized.

Not long since, I examined a case, where it occupied more than half
of the abdomen, and weighed between fifteen and sixteen pounds. Consid-
erable portions of it were scirrhosified — tubercles abounded — the gall bladder
was greatly distended, and contained sixty-eight very large encisled calculi.
Eight inches of the colon firmly adhered to it, and so embedded and incor-
porated with its substance, that it were difficult to have separated it even by
dissection. The stomach, preternaturally small and apparently sound., w'as
thrown out of its proper location, and laid vertically, in the left hypochon-
driac, concealing a very diminutive spleen — considerable scirrhosiiy of the
pancreas existed, while the residue of the abdominal contents seemed only
to be anormal by a reduction of dimensions.

An overgrowth of the liver to nearly an equal extent, as in the foregoing
case, terminated the existence of the late Chief Justice Marshall. By the
magnitude to which this viscus had attained, — the stomach, dislocated from
its natural position, was forced into a perpendicular direction, its sides
pressed into contact by the liver, so as to obliterate its cavity, and he
being unable to retain nourishment, for it was rejected as soon as swal-
lowed, finally sank from inanition, after a lengthened continuance of un-
mitigated sufferings. 'J'hus perished this truly great and good man, leav-
ing a void in a sphere of usefulness, which, in the eloquent language applied
to another illustrious personage, no one could be found to fill, or who had
even a tendency to fill, and bequeathing to his country a name, that makes it
advantageously known in every enlightened portion of the world.

“Clanim et venerabile nomen
Gentibus, et multuin nostrse quod proderat urbi.”

Pathology. — Not much need be said of the pathology of this series of he-
patic affections. Many instances resulting from the imperfect cures of acute
hepatitis, may with propriety be considered as a more advanced stage of the
same disease.

Commencing idiopathically, the case assumes the modification produced
by a slower and more feeble progression of a similar morbid process. There
Is an identity, or nearly so, in the kind of action, though varied in the degree

361

Chapman on Diseases of the Liver,

of activity and intensity. But while some of the pathological phenomena
are to be deemed the ordinary results of inflammation, those of the more
irregular deviations, consisting in new formations of structure, must be
referred to vitiations in the nutritive functions.

It is by such interstitial depositions of scirrhous, steatomatous, tubercular,
or other matter, that the character of the liver, or any other organ is altered,
and being heaped on in excess, and without the plastic hand of nature to
model it, exchanges its definite configurations, and dimensions, for the rude,
enormous, and anomalous shapes, which these masses occasionally present.

Tracing the progress of this collection of anormal processes, it seems pro-
bable, that the first step, in most instances, is an undue afflux of blood to
the liver, productive of congestion, which, disturbing its economy, leads
on to those further changes, by which nutrition becomes irregular and
depraved, each being a link of a consecutive chain. That the liver receives
blood, under such circumstances, at the expense of the other abdominal con-
tents, is presumable, from its undue growth, and by the diminished size of
the organs with which it has the most immediate vascular connections.

As far as I know, this fact which, of late, has attracted some attention,
was first promulgated by myself. Many years ago I suspected it, and all
my subsequent inquiries in reference to it, have lent to its confirmation.
The converse I have reason to believe to be equally true, or when there is
an atrophy of the liver, and of an indurated texture, the spleen especially,
is in the same proportion, increased in bulk and disorganized.

Treatment. From the difficulty of determining the precise condition of
the organ, our practice is marked by no nicety of distinction, or exactness of
remedial application in these affections.

An examination, as we have seen, may in some instances satisfy us of
its enlargement. But whether this be owing to chronic phlogosis simply,
or to any of the more formidable changes of structure, which have been
noticed, no human perspicacity can positively divine.

Nor must we forget, that the liver may be most seriously affected without
any augmentation of growth. Confiding in symptoms, or indeed any other
signs, we shall generally be not a little perplexed, and very often egregiously
deceived.

Believing however, that the case consists in no material structural lesion,
that it is of comparatively recent date, and is caused merely by chronic
phlogosis, or incipient induration, and these perhaps are the only curable
states, the treatment best calculated to afford relief, is made up of moderate
and repeated venesection, of the use of cups, or leeches, to be followed by a
succession of blisters, or a caustic issue, over the region of the liver, aided by
occasional purgings. An impression thus kept up on the intestines, does
much to restore the healthy exercise of its functions. Calomel should be
freely given, with this view every two or three nights, to be worked off in
the morning with caster oil or Epsom salts, or magnesia, alone or united—
and, perhaps, something is gained by the addition of the tincture of colchi-
cum to the latter combination.

Among the secondary measures, various other deobstruents have been
proposed, the gum ammoniacum, the taraxicum, &c. The former of these
was much confided in by the late Professor Wistar, and several of the Ger-
man authorities, whether on sufficient evidence of its utility, my own expe-
rience does not enable me to say. But in regard to the latter, 1 have much
reason to suppose that it sometimes proves serviceable. It is particularly
praised by Boerhaave, Bergius, Zimmerman, and other writers of the
No. XLVIII. — August, 1839. 31

Monograph,

continent of Europe, and also by Pemberton of England, in his work on the
diseases of the viscera. Either the extract, or juice of the fresh leaves, is usually
directed. Confirmatory of the efficacy of the latter, I have to state a fact
which I learnt from a very intelligent grazier, that cattle penned during the
winter, becoming what is called livergrown^ are very soon relieved by
being turned into fields in the spring, abounding with dandelion. The an-
nexed I have found an excellent prescription, in the dose of an ounce, or
more, several times a day.*

Means of this sort failing, we are next to resort to a course of mercury.
But here a salivation, particularly a deep one, is in all cases to be avoided.
The object is to bring back the organ to its natural state, to be effected by an
alterative operation. Minute doses of calomel, or the blue pill, with opium,
are to be insinuated till the system is perceived to be under its impression,
denoted chiefly by an improvement in the secretions, and which is to be
maintained, without abatement, for several weeks, and in the more invete-
rate cases, with occasional intermissions, for months.

In the use of mercury, however, some discrimination is demanded.
Its salutary effects, under all circumstances, may be mainly ascribed to the
promotion of the biliary, and other secretions, and failing to do this, it proves
inert and nugatory, or causes a pernicious state of irritation, or positive phlo-
gosis, with an irregular febrile movement. In the management of the chro-
nic affections of the liver of every description, these are considerations which
should invariably control its employment — continuing or discarding it, ac-
cording to the mode in which it affects the system. Not a few instances I
have seen of hepatitis as well as of jaundice, in which the condition was
most unequivocally deteriorated by neglect of these practical maxims, and
some, where irreparable mischief was entailed by a lengthened persistence
in a mistaken course.

Disappointed with the internal use of mercury, or the bowels being too
irritable to retain it, inunctions may be employed. Nitro-muriatic acid
externally, as well as internally, is substituted for mercury, where the latter
has proved ineffectual, or-, for any reason, is deemed inadmissible.

It may be added, that, internally, some of the preparations of iodine, and
still more frictions with the ointment over the right side, have been used,
and that we are not without proof of their success. Yet I have seen
nothing myself to inspire any very great confidence in their efficacy. To
assuage pain, or to procure rest, or to remove undue irritation, opiates on the
whole are to be preferred, though the cicuta, henbane, belladonna, stramo-
nium, <fec., may be tried.

That, in these cases, reliance is placed mainly on mercury must be appa-
rent, and in recommending it, having previously mentioned it as one of the
causes of the disease, it may seem that I am guilty of an inconsistency. But
such an imputation is not just, and cannot be sustained. It is against the
abuse of the article I protest: and do not instances occasionally present,
where the same agent is the cause and the remedy of the disease? This
indeed is so true that we have the old aphorism, “similiasimilibus curentur.”
Take for illustrations of it, delirium tremens, the atonic states of the stomach
from intemperance, &c. Do we not frequently resort to that very stimulant
as a cure, which, improperly used, had produced the condition we are
endeavouring to redress? Like the fabulous sword, the rust on which healed
the wound inflicted by its point, mercury here cures the mischief it had occa-

* R. — Infus. Tarax. §iv; Extr. Tarax. ^ij; Garb. Sodae ^ss; Tart. Potass, Tinct. Rhei
aa ^iij. — M.

363

Chapman on Diseases of the Liver.

sioned. Even admitting that the case of hepatitis, we are called to treat,
could be indisputably traced to the undue employment of that article, it
would still be the appropriate means of relief. The liver being torpid, we
should recur to mercury, from its well known specific powers of exciting
and restoring its healthy functions.

An exception, however, may be found to the use of mercury in the atrophic
state of the liver connected, as formerly described, with a defect in the pro-
cess of hematosis. It is here the most pernicious of medicines, and, in place
of it, the martial preparations, the phosphate of iron yar excellence^ with a
well regulated animal diet, and exercise substituted.

Finally, I have to remark, that these hepatic affections, even when pretty
well eradicated, are very apt to leave behind a very impaired state of health,
manifested chiefly in derangement of the digestive functions, with general
debility and wretchedness of feelings. As this, however, constitutes a dis-
tinct pathological condition, interesting as it is, I cannot properly enter now
into the consideration of it, and must be content to refer, as a guide to its
treatment, to what is usually done in the inveterate forms of dyspepsia.

III. Congestions of the Liver. — From the peculiar character of the circu-
lation of the liver, which is more venous than arterial, we might presume its
liability to this pathological condition, independently of the direct evidence
of the fact. Its acme affections, indeed, of which I have already treated,
participate of this character, and especially in the early stage. But it is soon
supplanted by inflammation, or, if any of it remains, it is in so subordinate
a degree as to lose all prominency, and may be completely masked or con-
cealed. Engorgement simple, or unmixed with any other lesion, is the state
to which I have now reference. This occurs under very different circum-
stances, exists in diverse proportions, either partially or to a great extent,
and varies in its nature.

Symptoms. An attack, for the most part, is very sudden, or with little or
no premonition. Extreme languor, however, may be previously complained
of, soon followed by chilliness, with some degree of collapse — while, in
other instances, these precursory symptoms are altogether absent. But,
whichever may be the mode of aggression, a developed case of violence is
characterized by sensations of fulness of the liver, sometimes amounting to
an uncomfortable ache, or even positive pain, attended by an evident dis-
tension of the region of that viscus, and tenderness on pressure — by short,
panting, and laborious respiration, by nausea, and sometimes vomiting and
cramps of the stomach or bowels, and by a weak and emptied or a full,
struggling, interrupted pulse, without any febrile reaction, and occasionally
by haemorrhage. But, on the contrary, where the attack is lenient, or more
gradually comes on, most of these symptoms at first are wanting, and the
affection has actually endured for a considerable period, with scarcely any
inconvenience, or other evidence of its existence, save that derived from an
inspection of the right hypochondrium.

This affection is often one of the introductory symptoms of the cold stage
of malignant autumnal fevers, especially intermittents of this nature — and I
once met with it proceeding from the immediate influence of an exposure to
the low temperature of an ice house — and, in another instance, from a
copious draught of intensely cold water, when the system was heated and
fatigued. Examples are also reported of its being brought on by impedi-
ments to the circulation in the right side of the heart, leading to an accumu-
lation of blood in the liver, and we are told by Andral that it may be occa-

364

Monograph.

sioned in the foetus, by some mechanical cause, during parturition. But,
though sometimes it is thus induced, the case which I have more immedi-
ately in view is generally assignable to extreme heat, separately or combined
with miasmata, of the effects of which, there is abundant proof afforded in
our hot, low, marshy districts of country.

Diagnosis. From hepatitis this condition, when well marked, may be
distinguished by the suddenness of tlie invasion, the exemption from fever,
the peculiarity of the circulation, the obtuseness of the pain, the comparatively
slight sensibility to local pressure, and the aspect of collapse and exhaustion.

Prognosis. Engorgements of the liver, heavily oppressive, are always
alarming, and still more so in proportion as they ate passive, or occur in the
feeble, or during an epidemic prevalence of fevers. Differently circum-
stanced, they prove of far easier management, and are often speedily relieved.

Dissection reveals appearances according to the gradations of the affec-
tion. It having been vehement and extensive, we find the liver swollen
into large dimensions, with little change of consistence, and of a reddish pur-
ple, or of a dull brick hue. Dark blood, on an incision into it, flows out very
freely, and the interior structure is very much of the colour of the external
surface. Both the large and the small vessels are prodigiously injected, the
blood still retained in them, though sometimes there are extravasations of it
in clots, and in other instances, infiltration of it through the parenchymatous
texture, constituting an hepatic apoplexy. These effusions, as well as the
more copious haemorrhage, which may occur, seem to be owing chiefly, to
an exhalation from the minute extremities, and not to a rupture of any great
vessel — such an event having been very seldom observed. The lesions, how-
ever, which I have described, may be more partial, or limited only to por-
tions of the liver, the residue of the organ exhibiting little, or very slight
aberrations from its natural aspect and condition.

Pathology. Contemplating the phenomena of this case, in its ordinary
exhibition, it clearly appears to consist in passive, or very atonic congestion,
from a loss of that power in the vessels by which the circulating movements
are maintained. The same view is held by a celebrated writer, (Andral,) who
goes even farther, and declares, that in the worst form of it, at least, “ the blood
collects in the liver exactly as it does in the gums in scurvy.” Neverthe-
less, it is very conceivable, though I confess, I have never witnessed such an
instance, that the affection may present much greater activity than has been
represented. It is, however, probable, that any high degree of such a state,
could not long be continued, from its tendency to bring on inflammation, by
which conversion, we should have hepatitis.

Whatever notion may be entertained of its pathology, the great aim in the
treatment of the affection, must be to remove the concentration of blood, and
with integrity of constitution, this is undoubtedly best effected by copious
venesection. But if it be not admissible to such extent, or tried without suc-
cess, then to resort to cups over the affected part. Great advantage is de-
rived from emetics, owing doubtless to their power to emulge, or unload
oppressed organs, and to re-establish an equal circulation. Nor is purging
with calomel, on the same principle, of scarcely less efficacy. Blisters are
also useful. It will, indeed, be often found the best practice in the weaker
congestions, and especially when the vital forces are very languidly exer-
cised, that while depleting, to employ stimulants the most diffusive and ener-
getic. But to discuss this point as it deserves, would require a wider range
than I can now appropriate to it.

That such hepatic congestions, as I have had in view, ever become chro-

365

Chapman on Diseases of the Liver,

nic, does not very clearly appear, unless the state which I am next to notice,
may be so deemed. My allusion is, to what has hitherto been called:

IV. Hepaticula. This term is a diminutive of hepatitis, and was adopted
to express the smallest degree of the chronic stale of the latter disease. It
may, perhaps, in this sense, be sometimes properly applied, though I am
inclined to believe that the affection to which it is appropriated is, for the
most part, independent of inflammation.

The pathological condition, considered as hepaticula, is characterized by a
sallow complexion, more of the lemon than orange tinge, or sometimes by a
dingy while — by much laxity of the integuments, with the aspect of bloated-
ness, particularly of the abdomen, which is exceedingly tumid — occasionally
oedema of the lower limbs — dry, husky, unperspirable skin — shortness of breath
on the slightest exertion — costive bowels — clay, ash, or slate coloured stools —
deficient, dark, or loaded urine — sluggishness of body — hebetude of mind —
pevishness of temper, and dejection of spirits. The pulse is mostly little
affected, sometimes, however, feeble — while, in other instances, it is full,
slow, and may be intermittent, or otherwise irregular. No acuteness of pain
is felt in the region of the liver, or tenderness betrayed on pressure, the com-
plaint being rather of a disagreeable ache, or a severe sense of distension.
This state of things may continue for a long period without much alteration,
prone, as it generally is, to further degenerations. Commonly these are a
wasting, slow, irritative fever, heightened by an exacerbation at night, sub-
siding with copious perspiration, ultimately followed by colliquative diai-
rhcea, or it more speedily eventuates in haemorrhage of dark blood, or general
dropsy, or the whole united, or some other fatal disorder. It is familiarly
called throughout our Southern States, where it abounds, inward fever!

Examples of this affection are to be met with among persons of all ages^
though more so in children, habituated to the influence of miasmata.. Being
partially acclimated, as it were, this cause of fever, and; of the more special
disturbances of the liver in such positions, operates; with comparative light-
ness, and hence the only sensible effect is to swell aad derange that organ.
But it is also consequential sometimes on ill-cured iMer.mluent and other
fall fevers.

To discriminate between this affection and chrmiic hepatitis,, may be eni'^
barrassing on some occasions. Much, however, is to be learnt, with this;
view, at all times, from the general physiognomy, and tlie usual absence of
acute pain, and the other incidents of positive inflammation,are very decisive..

Commonly, in the beginning, or at an early stage, the affection is easily
removed, and reversely when it becomes inveterately fixed by neglect or
improper management — changes having then taken place on which salutary
impressions are rarely made.

Of the anatomical characters, I am not very accurately informed. The
liver is mostly enlarged, sometimes enormously, with a firmer texture
than natural, though I have seen it softer, and retaining pretty nearly its ordi-
nary colour — the external surface, being seemingly little affected, whether of
the serous covering, or of the organ itself. Dissection of it shows excessive
congestion, and dark blood issues forth very copiously. Few traces of un-
equivocal phlogosis have I observed. Differing from all this, the liver is
occasionally found of reduced dimensions, even actually atrophied, of a pallid
hue, and of a condensed consistence, with defective vascularity. No doubt
other, and perhaps more important, alterations take place, and, indeed, may
have been reported, of which, however, I have no knowledge.

31^

366 Monograph,

From this account it is, I think, to be inferred, that the real pathological
condition of the case is, that of venous engorgement of the liver, induced by-
torpor of the portal circulation, from the constant exposure to the operation
of miasmatic influence. But such a condition cannot long endure without a
tendency to further lesions — and it is reasonable to presume that these, in
some instances, do occur, even inflammation and its consequences.

In the management of these cases, we must be governed essentially by the
state of the system. The loss of blood, generally or locally, will be de-
manded where there is an increase of vascular action, or any considerable
fulness in the affected part, to be followed by counter irritation. But, this
exasperated condition not existing, we may at once commence the use of
purges, selecting those articles which operate more directly on the lower por-
tion of the bowels. Combinations of calomel and aloes, with the compound
extract of coiocynth, are well suited for this purpose, and an application of
leeches around the anus will be found very advantageously to co-operate in
the design of diverting the circulation from the liver to the rectum. An
alterative course of the blue pill may next be tried, and also the nitro-murialic
acid externally. The vapour bath is, moreover, very useful. Cases I have
repeatedly seen benefltted by it, and some where cures were promptly and
completely accomplished.

In the leucophleginatic variety of this affection, usually associated with an
atrophied liver, or indeed under any circumstances, of much debility, the
best remedies are the martial preparations, especially the phosphate of iron,
aided by a nourishing diet, exercise by swinging, or on horseback, or a long
journey if practicable. But, above all, should the individual live in a mias-
matic district, let him escape from it, by which alone cures are often effected —
and this is an additional reason with me for supposing that no essential dis-
organization exists in the case.

It remains to remark, that in many instances of protracted hepatic disturb-
ance, whether inflammatory or otherwise, after our best exertions have
proved abortive, relief is afforded by resorting to our mineral, particularly the
Sulphur springs, the best of which are those of Virginia. Eminently, how-
ever, as these are entitled to commendation, I am persuaded that not less
may be derived from the thermal baths of the Warm and Hot springs of the
same neighbourhood, each being adapted to meet different indications, and
should, perhaps, be brought to co-operate in the treatment of most cases of
chronic hepatic disease.

367

MEDICAL EDUCATION AND INSTITUTIONS.

Article X. The Gleanings in the East of a ci-devant Invalid^ in 1838,
By Valentine Mott, M. D., of New York.

Amidst the political and moral degradation of the Egyptians, we were
delighted to witness the attempts at the formation of a medical school, and
the establishment of well educated medical men among them. The countenance
and protection given by the Pasha of Egypt, Mahomet Ali, to Europeans to
reside in the country, is every where apparent. French, Germans, Italians
and English are to be met with filling important and responsible stations in
the army, navy, medical school, and about the court and person of this
celebrated eastern despot. Whether this be for selfish, or humane objects, is
a question which must naturally arise in the mind of every observer, who
travels in that country; and there are few, we think, who will not ascribe it
to the former. But a great general good to the Egyptians must nevertheless
flow, from this almost only wise policy of their cruel and hard master.

From a fear too no doubt, that a sufficient inducement could not be held
out, for foreigners of merit to take up their residence in this benighted
country, the Pasha has from time to time been in the habit of sending to the
medical schools of Europe, and particularly of France, a number of young
Arabs, to be educated at the expense of the government. In this way a
ready communication is had with the foreign practitioners and the native
eleves of the country, who assemble in the hospitals and medical schools,
until the former have acquired a sufficient knowledge of the Arabic language to
impart instruction to them in their native tongue. In this way we have wit-
nessed the lessons of the professor conveyed to the pupil by a young Egyp-
tian physician who had been educated in Paris, French being the language
used for this purpose. Tlie Arabic, as I was informed by the professors,
is extremely difficult to be acquired, and those only who had resided in the
country for eight or ten years, were able to read it and above all to speak
and understand it sufficiently well to hold intercourse with the natives and
impart instruction directly to the pupils.

The medical school of Egypt, which for some years has been located at
Aboii-ZabeU is now removed to Esbekie, in the immediate vicinity of Cairo;
the former being too remote from the capital, to enable the professors, from
their necessary duties in private practice, to do full justice to the institution.
The school makes part of a large and well arranged military hospital, beau-
tifully and pleasantly situated on the western bank of the Nile, in the
suburbs of Cairo. This hospital contained thirteen hundred patients when

368

Medical Education and Institutions,

we visited it. The immediate connection of the medical school with this
large hospital, together, making one great edifice, is in my opinion an
admirable arrangement for the benefit of the pupils, and well deserving of
imitation in other and more enlightened countries. The lecture rooms of
the professors are all exceedingly well arranged, and the amphitheatre for
anatomy is particularly well constructed, with an abundance of light
from a cupola on the top. A large and well arranged pharmacy, with spe-
cimens of every kind of domestic and foreign drug, while it abundantly
supplies medicines to the wants of the hospital, serves as a means of
instructing the students. A large laboratory is connected with it, in which
the new chemicals, such as alkaloids, and others, are prepared, to answer
the demands of the physicians, and at the same time extend information to
the pupils, by making them acquainted with chemical pharmacy.

The number of pupils attending the lectures at the time of our visit, was
two hundred and sixty. They are not only attendants upon the lectures of
the professors, but residents in the hospital, in order to observe the treat-
ment of the patients, and to become familiar with the almost endless forms
and features of disease.

They are all educated at the public expense, have their quarters in the
hospital, where they eat and sleep, and are obedient to a regular military
and medical discipline, and rank as sous aides^ in the surgical staff of the
army. Here they are compelled to remain from three to four years in the
constant pursuit of their studies, and in the regular observance of disease,
at all times obedient to the call of their superiors, and ready to administer to
the wants of the patients.

The beautiful order and methodical arrangements, as well as neatness,'
in every part of this establishment, surprised and delighted me. It unites
the activity of the French, with the cleanliness and good system of the
German hospitals, and therefore may be said to have the excellence of both.

The anatomical mnseum is very respectable, and will serve as the nucleus
of a good collection. It consists mostly of bones, casts, and wax models,
with the excellent tributary aids, of parts, and the whole subject, of the inge-
nious invention of Doctor Auzoux. From the expense of alcohol, and the
great waste, owing to the excessive heat and dryness of the climate of
Egypt, few or no specimens of morbid parts can be preserved as wet pre-
parations. They are compelled to resort to drawings and wax models, to
perpetuate their similitude.

The apparatus for the illustration of the physical sciences is neat, and
sufficiently ample.

The Civil Hospital is situated in the city of Cairo, and is located in a
spacious building, but recently one of the palaces of Mahomet Ali. It is
placed very favourably for good air, near the principal square of this very
curious and truly oriental city. It is an admirable transfer of the noble and
superfluous domain of a single individual to humane and charitable purposes,
to the wants, necessities, and the afflictions of the poor and the diseased.
As the medical officers informed me, it had only been established about one
year, and was but a beginning of an asylum, and a home, for the suffering
and the sick.

It contained between two and three hundred patients, besides apartments,
especially appropriated for a lying-in establishment. Although there is a
male and female department in the same building, there is the peculiar
eastern vigilance, and harem-like care, that the females shall not even be

369

Mott’s Gleanings in the East,

seen by the male patients. On no pretence, whatever, is any male admitted
into the female part of the hospital unless he be a professional man, and then
he must accompany a medical officer of the establishment, who only has -
authority to introduce him.

Connected with this malernite, is a school for the education of young wo-
men, to fit them properly to be accoucheuses or sages femmes. It has a well
organised class of young females from the age of fifteen to twenty, under
the care of a French professor, aided by a young Arab, whose acquaintance
with the French language enabled the pupils to comprehend readily the
lessons of the principal. The class consisted, on the day of our visit, of
sixteen. They were dressed as Europeans, were very neat and respectable
in their appearance, and exhibited various tints, and shades of colour, from
the tawny Arab, to the jet black Nubian and Abyssinian.

They were all assembled in the class, at their lessons, when we entered,
and were receiving instruction from the professor. 'J’heir note books
were in Arabic and French. I was requested to test the practical know-
ledge of one of them on the mannikin. One, the most convenient, and as
black as ebony, was requested to come forward. Different questions in
French were put through the young Egyptian, and on the machines the
pupil proved by her manipulations with the fcetus, that she not only compre-
hended perfectly the question, but that she understood well the subject.

When their knowledge is thought sufficient, they are permitted to exercise
the art upon the patients of the institution. In this way, after a residence of
some time in the hospital, subjected to regular discipline and instruction,
they become very competent practitioners of this branch of the profession.
They informed me that all of them were educated at the expense of the
Pasha, and that his object was to place them in the harems, and thereby
dispense with male obstetricians; that Mahomet Ali, from time to time, was
in the practice of purchasing young females at the slave market at Cairo, and
placing them in the maternile for instruction. In this way he kept up a
constant supply for the wants of the different harems of his family and fa-
vourites.

This establishment is undoubtedly founded upon the liberal and humane
plans of the French, who annually educate, and send forth a large number
of well instructed and competent young women, not only in every direction
through their own provinces, but into other countries. It is to be hoped,
that in Egypt, a more enlarged and liberal view will be taken of this system,
and ere long that its salutary and benign influence, will be extended, far
beyond the gardens and walls of the harems; and that the almost count-
less poor, may receive something in return for what they labour so hard to
support.

Every facility seemed to be afforded in this obstetric school, in prepara-
tions, apparatus and instruments, as well as the living subject, to make the
pupils competent and useful practitioners.

An attempt is making at Athens, the present capital of the modern
Greek empire, to organize a medical school, by several well educated and
respectable Bavarian physicians and surgeons, who are attached to the court,
and whom King Olho has induced to settle in his country. At the time of
my visit, (April 1838,) they had from nine to twelve pupils, natives of the
country, who were lectured to by the Germans in the modern Greek lan-
guage; the professors from a residence of several years in the country,
being able to impart instruction to the pupils in their native tongue. Although

370

Medical Education and Institutions,

it is the merest beginning of a medical school, it is nevertheless praiseworthy
and honourable to its present founders, and may be the germ of an institu-
tion, which shall move onward hand in hand, with the regeneration of poor
fallen Greece. It may be, that from this embryo of a medical school, in far
distant time, the continent and the islands may echo again with the fame of
another Hippocrates, an Erasistratus and a Heriophalus.

Athens possesses at this moment a most excellent military hospital, ar-
ranged upon the modern European plan, capable of containing very com-
fortably several hundred patients. Also a highly respectable and well
arranged cabinet of Natural History.

Even in the mighty capital of the Ottoman empire, Constantinople, the *
light of medical science is beginning to dawn. A medical school is already
commenced, under the sanction of the noble, and enlightened Sultan Mah-
moud. The teachers are all Europeans, mostly Italians, and they are
giving instruction to from fifteen to twenty native pupils.

From what I saw of the diseases of Greece, both in the hospital at Athens,
and in the practice of two of the physicians attached to the court of King
Otho, they appear to be generally of an inflammatory character. This is
especially true with those of a febrile form, and the brain seems to be the organ
in which this is most particularly manifested. All their endemic fevers com-
mence with strong synochal symptoms, and are remarkably fatal to new
comers during the cerebral determination. If they escape from this stage,
they are precipitated very speedily into a profound typhus, or it assumes an
intermittent fever of the quotidian or tertian types. These latter, continue
with great obstinacy in defiance of quinine and arsenic, and frequently ter-
minate fatally in general hydropic effusions, and hypertrophy of the spleen.

'I'he Greeks are generally a very temperate people, and from living in a
mild climate, subject to few sudden variations, and an atmosphere the purest
and possessing a clearness and transparency that far exceeds any thing I
ever met with in any other country, are consequently a hardy and vigorous
race. The great distance at which an object can be seen, and the deception
thence arising in the computation of hours or miles in travelling, was a
frequent remark with my companions and myself, and we found that the
same thing had been noticed by foreigners resident in the country.

It ought to be recollected by all who visit Greece, that an abstemious
mode of living, and particularly great moderation in the use of stimulating
drinks, is essential to the preservation of health. From my own observa-
tion less wine can be borne in that climate, than in any I ever visited.
Every year at Athens I found that the endemic fever was fatal to many Eu-
ropeans, from imprudence in indulging in their accustomed quantity of stim-
ulating drinks, particularly wines. Although the wines of the country
generally, are not agreeable to travellers, from a strong lerebinthinate im-
pregnation which they give them and which they consider one of their
excellent qualities, the good wines of France and Spain are to be obtained at
Athens and Romania di Napoli; and at the latter places the delicious
wines of some of the Islands of the Archipelago, as Samos, Tenedos, &c.
may also be met with. All these wines, though lighter and milder than those
of Europe generally, ought to be indulged in sparingly.

An autopsy, which took place during my visit to Athens, confirms the
statement above made of the inflammatory character of the febrile diseases,
and that the serous membranes of the brain, the arachnoid and the pia mater
are the seat of inflammation. From a single case no one would be war-

371

Mott’s Gleanings in the East,

ranted in drawing a general conclusion, but when that case is said by pro-
fessional and competent judges, to be a good specimen of the common
appearances after death, it authorises the induction.

Shortly after my arrival at Athens, I was waited upon by Dr. Razor,
physician to the Queen, to witness an examination of the body of a favourite
femme de chambre of her majesty, who had died after a few days illness of
fever, attended with great cerebral determination. As he anticipated and
predicted there were evidences of inflammation of the two inner coverings of
the brain, with serous effusions, between the dura mater and arachnoid mem-
brane to account for the fatal issue of the case.

The Lepra of Greece, I had long felt a great desire to examine, and took
the opportunity of visiting some cases of it through the politeness of Dr. R.
and of making numerous inquiries of him as to the general character and treat-
ment of this ancient and curious disease. It bears a very striking resemblance
to the venereal disease, in its primary and secondary or confirmed stages. So
marked indeed is the coincidence, that it does not appear to me to be going
too far to say that it may be the parent or progenitor of lues veneera. It
attacks primarily the genital organs, then the throat, skin, and lastly the bones.
It is generally a more chronic affection than lues as we commonly see it, but
it assails the same parts and resemble^many cases of lues, such as I
have often seen; so much so, that Dr. Jackson of New York, my travel-
ling companion, as well as myself, confessed, that it would not be in our
power to discriminate between them. The lepra on the genitals, and in
the throat is commonly attended with more hardened and elevated ulcera-
tions, with more hypertrophy of the surrounding tissues, than ordinary
cases of lues, but such precisely, as I have seen in the venereal disease.
The affection of the skin resembles the worst and most vitiated forms of
syphilitic eruption, such for example as the large elevated, conical and con-
centric scab.

Such is the horror that the Greeks have of this disease, that they
abandon their dearest and best friends; and the unfortunate victim is fre-
quently obliged to seek refuge among the beasts of the field, and in the
recesses of the mountains. An instance of this I saw in the plains of
Argos, of a wretched man, affected with this loathsome malady, shunned by
every one, friendless and homeless. Even when it appears among the
better part of these people, it is considered a sufficient ground in either
sex for a divorce, and it is sanctioned both by the civil and ecclesiastical
laws.

Lepra is no longer considered as an incurable disease. It is more intrac-
table and obstinate than common forms or cases of lues venerea, but is found
to yield to proper treatment. The remedies most successful, are the same
as in syphilis — mercurial and arsenical. Of all the forms of mercury, the
corrosive sublimate, with sarsaparilla, is found the most efficacious. In obsti-
nate cases, after the mercurial treatment has been long continued, without
curative effects, the arsenical is substituted with the happiest results. The
analogy here, too, is very striking, as every one must have observed the
same thing in the treatment of the venereal disease.

In Egypt we found the lepra to assume the same features, and to be
treated in the same way by the European practitioners, as it was in Greece.
Syphilis, in all its forms, is also very prevalent in both these countries, but
is a much more mild disease, and yields more readily to remedies, than in
Europe or America.

372

Medical Education and Institutions*

The dry and arid climate of Egypt, while it seems to render these dis-
eases more mild, and particularly syphilis, produces in the Arabs a variety
of obstinate cutaneous affections. We saw many cases of the different
forms of porrigo, but it readily yielded to cleanliness and the application of
an ointment composed of equal parts of lard or common cerate, tar and
powdered charcoal. Want of cleanliness alone, cannot be said to cause
this affection, as the Arabs generally are worshippers of the Prophet, and
have their heads shaved, and observe the ordinances of their religion, with
much more exactness, punctuality and fidelity than the Christians. Before
they turn their faces towards Mecca, and offer their prayers, which are
most imposing and solemn, they invariably wash their faces, hands and
feet; and this they do, three and five times in twenty-four hours. The
other parts of their bodies receive very little attention, and consequently, are
in a more filthy condition.

The Egyptians are a very temperate people from necessity; there is no
wine or ardent spirits peculiar to the country. To this, more than to cli-
mate alone, we would ascribe the greater readiness with which their diseases
yield to treatment. From the state of nature in which they live, there is
very little predisposition to inflammation; and hence the readiness with
which they recover from woun^J^, and the remarkable success of surgical
operations.

The salutary and desirable process of union by the first intention, or adhe-
sion, is much more common and complete than in any part of Europe, or even
in America. This has been ascribed by some, to the heat and dryness of the
climate alone; but we would give a part of the credit to the sound and
natural constitutions of the Arabs. In the more civilised and refined coun-
tries of Europe and America, there is frequently either too much inflamma-
tion, or too high a degree of irritability, to have this object accomplished.
Both these states of the system, are well known by every surgeon, to inter-
fere with, and indeed, frequently to frustrate this process entirely.

Even the wound made in the operation of lithotomy, which is performed
in the lateral way, except that the prostate and neck of the bladder are cut
directly downwards towards the rectum as recommended and practised by
Vacca, frequently heals by the first intention, as I was informed by Dr.
Primer, a very intelligent and distinguished German surgeon, at Cairo, who
ranks high in the confidence of Mahomet Ali.

My experience in. New York warrants me in saying, that the adhesive
inflammation is, cseteris paribus, more favourable for union by the first inten-
tion, during our hot seasons, than in the cold weather of winter. I’his I
have noticed in an abundance of instances, and have been in the habit of
ascribing it to the lesser degree of inflammation that follows operations and
injuries in the summer months.

Aneurisms are almost unknown in Egypt. Dr. P. informed me, that,
during a number of years of extensive private practice and hospital practice
he had had only one case requiring an operation. It was a ligature upon
the brachial artery. I presented him with a set of the American instru-
ments, for conveying the ligature beneath the artery, and showed him the
manner of using them; with which beautiful, simple and ingenious inven-
tions, he assured me he would make an application of the ligature in the
first case which came under his care.

Since visiting a number of oriental cities, it is no longer surprising to me
that they should, from time to time, be scourged with typhoid forms of dis-

373

Mott’s Gleanings in the East,

ease, and particularly, the appalling and terrific forms of it, denominated the
peste or plague. As long as their cities remain, and their habits continue,
it must be, from time to time, the companion of the Mussulman. The fea-
tures and appearance of this disease, like the Asiatic cholera, are frightful
indeed, from the overwhelming operations of the contagion, infection or
poison that produces it upon the nervous system. It certainly resembles
the effect which some of tlie more deadly vegetable and animal poisons pro-
duce upon animal life. From the mild vegetable miasm that produces
intermittent and lemittent fevers, there is a variety of causes, vegetable
and animal, differing in intensity and violence, until we arrive at the most
concentrated of all, which is the niaferies morbi of plague itself.

From the facts which I collected at Cairo, Alexandria, Smyrna and Con-
stantinople, in each of which places the disease existed, and in the first of
which 1 saw a number of cases, my belief is, that it is not contagious, but
infectious and atmospheric. Dr. Bulard, the distinguished and intrepid
French physician, whom I met in the East, and with whom I returned to
Europe, has been several years immersed in the plague, visiting those cities
in which it prevailed, for the purpose of investigating its nature, and the
causes that produce and influence it. As we performed our quarantine
together at Orsova, I had an opportunity of collecting many curious facts in
relation to the disease, and at the same time becoming acquainted with many
of his views and opinions.

He does not befieve the disease communicable from one person to another
in the pure air of the country; they must be, as he says, in a pestiferous
atmosphere. In three instances, in which the clothes from the dead body
were worn by three individuals, two took the disease, but the experiment
was made in an impure atmosphere. He thinks it would not be communi-
cated in this way, in a pure air. It cannot be transmitted by inoculation
with the blood from patients labouring under the disease. He informed me
that he had made more than one hundred trials with the blood, at different
stages of the complaint. He even doubted that inoculation with the matter
from a charbon or inguinal bubo, would produce the disease out of a pes-
tiferous focus.

Doctor Pruner of Cairo informed me, that he never knew an instance of
plague to follow an autopsy, among the pupils of the hospital, and that
they made post mortem examinations of plague subjects, as freely as those

w'ho die from other diseases. Dr. of Alexandria, stated to us, that

he sent the clothes and mattrass, of a person who had died of plague, to
London, and that a quantity of the discharge from the charbons and buboes,
W'as mingled with them, and cotton was imbued with it purposely. It
arrived safe, was taken home, but no disease communicated by it. His con-
fidence in the non-contagiousness of plague w'as so great, that he was
induced to make this bold and unjustifiable experiment.

In the astonishing number of autopsies, which Dr. Bulard made in Egypt,
Asia Minor and Constantinople, amounting to upwards of six hundred, he
found the morbid appearances very varied. 'J'he brain, the stomach, intes-
tines, liver and spleen, were the organs generally either congested or
inflamed. One of these organs was sure to be found in the above men-
tioned stale, if the patient survived the initiatory stage, or collapse of the
whole system which ushered in the disease. Many perish in this stage.
Those who survive it, require a very guarded and cautious depletory Ireal-

No. XLVHI. — August, 1839. 32

374 Medical Education and Institutions.

ment, from a fear of the secondary collapse, which too frequently also is
fatal.

As far as I could ascertain, there is no settled method of treatment among
the practitioners of the East. All are very cautious in depletory means, and
particularly venesection, yet leeching and cupping may be and are resorted
to. Another will say, that quinine in large quantities, from the commence-
of the attack, is the only chance the patient has, in from five to ten grain
doses, several times a day, and continued through the stage of excitement.

From the great discrepancy which I found to exist in the treatment of the
peste, and from what I saw for myself, it should, in rny opinion, be treated
upon the same principles as an aggravated form of malignant typhus.
Always bearing in mind the necessity of watching very closely for the
unexpected collapses, which suddenly and fatally steal upon us.

375

REVIEWS,

Article XI. Outlines of the Institutes of Medicine: founded on the
Philosophy of the Human Economy, in Health, and in Disease. lii
Three Paris. Should we build facts upon facts until our pile reached
the heavens, they would tumble to pieces unless they were cemented by
principles.-— By Joseph A. Gallup, M. D., 2 vols. Boston:
Oiis, Broaders, Company, 1839. pp. 416 and 460, 8vo.

Dr. Gallup has been long known as an author, and in the north-east-
ern section of our country, as a medical teacher. In 1815, he published
a volume of more than four hundred pages, entitled, “ Snetches of Epi-
demic Diseases in the state of Vermont.'^ For many years he has been
a lecturer on different branches of medical science in more than one of the
Vermont schools; and as “ more than seven seplenaries of his life,” as
he tells us, have been spent in the active practice and the diligent study
of his art, his name is far from being an utdvnown or a new one in the
annals of American medical literature. He now presents himself to the
public with two additional volumes, bearing the old, but to us somewhat
indefinite, title of the Institutes of Medicine, embracing, we have a right
to presume, the final conclusions, the deliberate and digested results of a
long and busy life. As medical journalists, we cannot, of course, pass
by an original work of such pretensions; and even if our inclinations
might prompt us in the present instance to be silent, there is resting upon
us a high duty to the profession, which we do not feel ourselves at liberty
to disregard. This duty it is our intention now to discharge, fully, faith-
full, honestly, in strict justice to Dr. Gallup, and in like strict justice to
the profession, so far as upright purposes and such ability as has been
vouchsafed us shall enable us to do it. Dr. Gallup’s work claims, indi-
rectly at least, to be a natural system of medicine; in it he says, the fun-
damental principles of the science are at stake, and he makes his appeal,
boldly and frankly, to the “ honest sentiment of the community of medi-
cine,” for approval or disapproval of his labour. This is fair, and as one
member of that community, we shall take him at his word. As he him-
self says, “ whilst we respect characters, we must be free with princi-
ples,” and in the animadversions which we shall feel called upon to make
on many of the doctrines of his book, we shall aim to be guided by a
single eye to truth, to impartial judgment, and to the interests of our
science. VVe have no other purposes to answer, than the attainment of
these ends.

The Outlines of the Institutes of Medicine are arranged in three great
divisions — to wit; those of physiology, pathology, and therapeutics.
'I'he subject of physiology occupies 226 pages, that of pathology is
extended over 264 pages, and 273 pages are devoted to the division of

37e

Reviews,

therapeutics. Nearly one hundred pages of vol. 2d are appropriated to
a new system of nosography.

We have but little to say, generally, of our author’s physiology, except
that we are wholly unable to discover the right of this department to a
prominent place, or indeed to any separate place in the Institutes of Medi-
cine, as tliey are called. These, says Dr. Gallup, may be defined as
“ that science, which embraces a knowledge of diseases and their reme-
dies.” This definition makes the Institutes of Medicine synonymous
with ’practical 'medicine, and with the theory and practice of medicine.
If these several terms are not absolute syno!iyma, then we suppose, that
by the former, as contra-distinguished from the latter, must be meant the
general principles of pathology and therapeutics, in the abstract, or the
philosophy of pathology and therapeutics, and not the knowledge of indi-
vidual diseases and tlieir treatment. If this is the true supposition, our
own opinion of the legitimacy of such a distinction and of the grounds
upon which it rests will become apparent in the course of our remarks.
In either case, we still fail to see the alleged relationship. Certainly a
knowledge of physiology is necessary to a full knowledge of diseases and
of their remedies, but no more so than is a knowledge of anatomy or of
mateiia medica. They are all co-ordinate and independent branches of
the same science, mutually and intimately related each to each, and each
to all, but not subordinated in regular gradation one to another. Dr.
Gallup’s 226 pages are made up, for the most part, of the simplest ele-
mentary facts of physiology, strictly so called, and of physiological or
general anatomy, with but little merit either of arrangement or exposition.
Such inaccuracies as c2Wmg fibrine, effused from inflamed serous surfaces,
dense serosity, of slating the results of the experimental physiologists in
relation to the functions of the different parts of the brain as positive and
absolute, we have no wish to single out for special remark. We cannot,
however, dismiss this division of the outlines without taking a fuller
notice of one of its doctrines: indeed, should we do so, our author himself
might justly complain of us, since the doctrine to which we allude is
evidently one of his very particular favourites. It has reference to no-
thing less important than the independent and absolute nature, origin and
operation of the principle of life; that peculiar and mysterious power,
always, heretofore supposed to be associated during this state of existence
with organic matter, which has received so many names, and which has
been the subject of so much vague speculation and conjecture. Before
plunging into the vast inane of the question, “ What is life?'^ the Dr.
seems to have had some slight misgivings — not as to the ability of the
air, into which from his philosophical heights he was about to launch —
to uphold his waxen wings, but as to the opinion of his fellow mortals,
standing on the solid ground below, of the safety and sanity of the enter-
prise on which he was about to enter. “ It appears,” he says, “ that
philosophers are required to have every thesis guarded, and supported by
demonstrations drawn from tangible experiments, and so conclusive as to
compel assent; that nothing can be taken on trust, or by analogical induc-
tion. These lines have of late been drawn so straight as to impede inves-
tigation on subjects, which in their nature cannot admit of mathematical
or chemical demonstration. However, it may be noticed, that undeniable
facts may be well shown by a series of circumstantial and analogical indi-
cations, which may compel tlie assent of the mind as certainly as direct

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testimony, and so it is now held and practised in courts of judicature.”
But Dr. Gallup is not a man to have his investigations impeded by these
straight lines of this modern logic; his is not a genius to be cramped in a
pestle and mortar, and the fruits of this high soaring are the doctrines
which we proceed to state.

The vital principle, or as Dr. Gallup calls it, the vital entity^ is not an
“ evanescent nihility f the result of organization, or its inseparable
dependent, but an exquisitely subtle essence, gas, aura, or spirit, existing
by itself, co-eval and co-extensive with the existence of matter, and con-
stituting, when attached to matter, manifest, organic life. This principle
pervades universal nature, and is ever ready and on the look out for an
opportunity to attach itself to “ certain molecular forms of matter,” by
which union it is enabled to enjoy and to manifest its peculiar properties
and phenomena, or in other words to live. “The myriads of myriads of
ephemeral insects that darken the air, or of reptiles which separate the
foot of man from the surface of the earth, all springing into life at tiie
same time, and simultaneously giving up the ghost and becoming extinct,”
cannot be accounted for, we are told, on the supposition of a seminal or a
sexual origin. 'S'hey are the result of the coalescence of this vital aura
with the molecular forms of matter, the products, in short, of what has been
called spontaneous generation. As illustrations of the action of this principle
we are referred to the proofs furnished by the fossil osteology of some of
the early geological formatitms, of the former existence of animated tribes
which have long been extinct, and of the subsequent creation of others,
“ so far as can be discovered,” says Dr» Gallup, “ without a direct semi-
nal origin.” We are further referred to Genesis for evidence of the
reality of this “ universal generant influence.” 'I'he doctrine is gravely
argued from the phraseology of the Mosaic account of the creation, and
thus this sublime and mysterious act of Jehovah himself is seriously attri-
buted to the agency of a fecundating principle, or germinating aura.
We have no intention of so far presuming upon the patience and good
nature of our readers as to reply to these worse than ridiculous fancies*
It is quite enough for us to stale them. They liave but one parallel, that we
know of among modern works of science, and this is to be found in Mr.
Kirby’s Bridgwater treatise, a book, the preliminary chapters of which
are more crowded with concentrated folly and sublimated nonsense, tlian
any thing else of the present century, that has come under our observation.
Our author could hardly have been aware of the existence of Mr. Kirby’s
specidations. He could not have been so unkind as. to have passed them
by without any tokens of recognition. Mr. Kirby is of opinion, that all
parasitic animals infesting the human body—in vulgar phrase, lice — have
been created at different times, since the fall, in order to punish and tor-
ment men for their sins, l.e Clerc and Bonnet, it seems, thought it more
probable, that all these worms existed in Adam before the transgression,
under tlie form of eggs, which did not hatch till after that event. How
many difficulties, which must have perplexed the mind of the learned
British naturalist, philosopher and divine, would have been removed, had
he only been aware of the existence and the properties of the “universal
generant influence, or germinating aura?” 'I'here is one other attribute
of this vital entity, which we have not yet spoken of, and which, trusting
only to our a priori reasoning, we should hardly have looked for. It
seems to be a fountain sending forth bitter as well as sweet waters, a vine

32*

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bringing forth thistles as well as grapes, a tree of death as well as of life.
Dr. Gallnp suggests, that epidemic constitutions of the atmosphere may
consist simply in an undue and extraordinary concentration and accumu-
lation of this subtilized dura, and as a sort of support to this suggestion,
we are told, that attacks of severe disease are often preceded by a stale of
high and refined health in the individual, and that the prevalence of the
plague is attended with increased activity of the sexual appetite!

We are sorry to be under the necessity of convicting Dr. Gallup of
plagiarism in this last matter. We would not willingly pluck so green a
leaf as this, from his philosophic garland; but the heart-hardening obligations
of justice and criticism, leave us no alternative, and we must proceed in our
painful duty. It is well known that, during the last seven or eight years
of the eighteenth century, the yellow fever prevailed very extensively and
fatally in most of the large cities along our Atlantic coast, and that a great
deal was w’ritten in relation to its causes. Among other works upon this
subject, was one published in iNew York, in 179H, entitled a “ Physical
Inquiry into the Origin and Causes of the Pestilential Fever. The
author thinks that the ancient doctrine of the four elements is right, as far
as it goes, but that two others ought to be added. One of these is elec-
trical fire, and the other is a universal agent, which he calls mother.
This mother, he says, is the great agent of vegetable and animal life.
He says that it differs essentially from air; that its native region is the
surface of the earth; and that it does not descend deep into the earth, but
by compulsion, although at times it is forced very far downwards; but
that, even if it should be drawn to the centre of gravity, or to the bottom
of the ocean, it will eventually make its escape, and rise to its natural
station upon the surface again. This mother, he adds, commonly rises
pure, but it sometimes gels contaminated by combining with other things,
especially during the putrefactive process, while the hot season prevails.
The mother, thus vitiated and venomous, rises up, defiling the earth and
water through which it passes, and by its action on the human system,
occasions pestilential fevers. Tire identity of doctrine here is manifest,
and our author’s claims to the distinction of discovery must be wholly
abandoned, unless the result of another Leibnitzo-Newtonian controversy
should show that the glory really belonged to both, both having arrived at
the same great result independent of each other.

Leaving the physiological portion of the book, we at length arrive at
more inviting regions^ and we are ushered into the province of pathology
with a flourish of trumpets of no equivocal or uncertain sound.

“ In the outset,” says Dr. G. “ we indignantly repel the trite, sarcastic
inuendoes, which have so often uncoKrteously been cast by many; by direct
allusions to theorems advanced, having been termed from lamp-light cogitations
in the closet; and the bending of facts and analogies to support a favourite hypo-
thesis. We have been inducted by another, and more hardy routine of study.
And, from the full conviction of the insufficiency of every generalization hitherto
attempted, have re-explored the chartless empire of medicine; and wishing to
save it from the quicksands of empiricism, have made many comparisons in
the open air, in the dissecting room, and at ‘the bed-side of the sick.’ Having
a few incontrovertible data, as polar stars in view, we have endeavoured to form
inductions, which wull not readily be dissipated by the fire of experiment. If
the arrangement is new, it is supported by facts not altogether novel.

That this is no fanfaronade, is immediately manifest on turning the leaf

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which contains it, for directly on its opposite and corresponding surface,
we have the annunciation in three pregnant lines, of the great fundamental
principle of pathology, so long sought, and so late discovered — a princi-
ple which is to be to the physician what the Newtonian law of gravitation
is to the astronomer. The two pages stand in beautiful relation to each
other; the latter fulfilling all the high promise of the former — “ fit body
to fit head.” The following is our author’s statement of the new doctrine,
which is to lead the- bewildered pathologist from out of the intricate and
labyrinlhian paths in which he has so long and so blindly wandered —
baffled and sore perplexed — up into the light and sunshine of the per-
fect day.

“ The excellency of Sir I. Newton’s improvements in physics, does not con-
sist in having discovered the principle of attraction inherent in inert matter, but
in having shown that attraction acts directly in proportion to the mass of matter,
and inversely as the distances. Is it not possible to offer a clew, which may lead
to an unfolding of the laws of organic life upon an axiom almost equally simple
in character and construction, and which may serve as a guide to the pathologist,
through the intricacies of his searches in relation to disease! The vital force
responds directly in proportion to the integrity of the organization, and is eqiuva-
lent to the compatible or incompatible range of stimulations applied.'^''

We hope that no pathologist will hereafter suffer himself to be troubled
with foolish and unreasonable doubts in relation to any of the questions
which he is called upon to answer. The open sesame is here put into
his hands, and it is his own fault if he does not unlock, with its magic
power, the doors which have hitherto barred him out from that region into
which he may now enter, to clear up the mysteries of disease, and to
unfold the laws of organic life. The great elementary pathological axiom
is at length established; the formula, by the application of which, all the
manifold, confused and ever shifting phenomena of disease shall arrange
themselves in harmonious order, and refer themselves with quick and
infallible certainty to their simple and ultimate causes is finally discovered,
and it is this: “ The vital force responds directly in proportion to the
integrity of the organization, and is equivalent to the compatible or
incompatible range of stimulations applied.'^

Like a faithful pastor, who avails himself of any striking or unusual
visitation of Providence, to impress upon the hearts of his people, the
truths and obligations of his faith, we take this occasion to enforce upon
our readers, the immense practical value of great pathological principles
like that just stated. It must be borne in mind, that Dr. Gallup’s work
is “founded on the philosophy of the human economy, in health and in
disease.” He rests his rules of practice on his doctrines of morbid action.
His therapeutics is deduced from his pathology. He is a rationalist and
no empiric. Now who can fail to see how naturally the only true method
of treating — not diseases, but disease and all disease, flows from the above
pathological axiom! Who can doubt after this is once clearly and fully
comprehended, whether Dr. Gallup’s treatment of typhoid fever, or Dr.
Miner’s, is right? Who can hesitate any longer between quinine and
blood-letting in erysipelas? Of what use aie all these statistics, and this
irksome, drudging, endless study of positive results, this counting and
weighing of cases, when the whole matter can be thus packed into a nut-
shell? How much easier it is to be governed by these rational principles,
than it is to attempt to follow the uncertain and contradictory guidances of

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experience! Henceforth, then, if a physician who may be visited with
such misgivings as have heretofore at times beset even the best of us,
should liave any doubts as to the safest management of his patient with
rheumatism, or typhus, or phthisis, let him turn away from the fallacies of
observation, to that oracle of medical science which has been the text of
this commentary, and he shall doubt no longer; his knowledge shall be
clear, absolute and complete.

The patliological division of the work is arranged under three separate
heads. These are pathology strictly so called, etiology and semeiotice.
The first subdivision contains eleven sections, some few of which, in the
prosecution of our design, we now proceed to notice. The second sec-
tion of this subdivision, and the fourteenth of the book, has for its title
“ What is Disease?''^ a question that has answered the excellent and
profitable purpose of tasking and baffling the ingenuity of medical syste-
niatists, from the time of father Galen, or earlier, down to that of Dr.
Gallup. To whom, among the countless multitudes who have tried their
wits at the verbal defining of a subject, which, for all practical ends every
body understands, belongs the palm of victory and success, w'e shall not
undertake to determine. That our author is at least as happy in the
framing of a definition as he is in the conception and statement of a prin-
ciple is abundantly shown in the present instance. The following are his
words: — “ With respect to a short definition of disease generally^ or the
morbid habits we might say that it consists in a manifestation of a series
of phenomena, indicative of the repulsive powers of the instinctive
energies of the living systemd^ This is certainly very clear.

The four sections, from the sixteenth to the nineteenth, inclusive, we
shall pass over. One of the leading objects of the pages occupied by
these sections, is to establish the doctrine of the nosodynamic character,
as Dr. Gallup calls it, of disease. He regards all disease as essentially
sthenic in its nature.

The twentieth section has this question for its caption: — “/s disease pro-
duced by extensive constitutional changes, and thence forming local
concentrations; or does it originate at some tissual point, and from
thence radiate over the entire organization?'^ The doctrines which it is
the purpose of this section to establish, may be thus briefly slated. Ail
disease is primarily general. Local affections are a result, and not the
original cause of the general excitement. The former depend upon the
latter; the latter does not depend upon the former. 'Jffle local lesion, in all
cases, acute and chronic, is only a concentration of the general nosodynamic
force, as Dr. Gallup calls the constitutional disturbance. This nosody-
namic force cannot act for any considerable time, without being accumu-
lated upon some focal point, and after it has thus fallen upon some organ,
or tissue, then there is a reflex or reverberating action of greater or less
intensity, according to circumstances. The radiations of local injuries or
irritations over the system, are transient in duration, and trifling in effect,
unless a morbid habit exists at the time, or directly supervenes; and in
this event, they become tlie foci of the general diseased state. The
capital leading points of Dr. Gallup’s system of pathology, are then these
two; — the sthenic character of^ all disease, and the secondariness or
dependence upon a general morbid habit of all local affections.

We have no wish to visit these doctrines with undiscriminating censure.
The chief objection to them consists in their claims to absolute and univer-

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Gallup’s Outlines of the Institutes of Medicine.

sal application. Dr. G. has here fallen into the common error of those who
endeavour to establish any other principles or axioms in medical science,
thati such as are the natural, necessary, inevitable expression of facts, cor-
rectly estimated and analyzed; — that of premature and gratuitous general-
ization. As a positive generalization or law, as a universal fact, the fore-
going doctrines are false; at any rate their truth is not demonstrated. Ilut
that as pathological views they are true to a certain extent, in relation to
many morbid conditions, there is good reason for believing. 'I'hat they
are true to a much greater extent than is now generally admitted, we cer-
tainly shall not deny. We do not think that this is a case where positive
and dogmatical assertion, either one way or the other, is allowed by the
spirit of a true philosophy. But we are ready to admit, that the same
philosophy may justify us in the cautious formation of mere opinions.
And we think that the doctrine of the constant and essential locality of
disease is by far too generally adopted. This is one of the fruits of the
Broussaisean system. As a natural result, the condition of the general
habit in disease has been, we think too much disregarded. In our exclu-
sive thoughts of the local and more easily appreciable lesion, w'e have for-
gotten the constitution itself. In our search for the tubercular deposite,
and in our study of its phenomena, we have too much overlooked the
depraved condition of which the former may have been only the conse-
quence. It is in this respect, especially, that the English practice seems
to us superior to the French. In this country the doctrines of Abernethy
have been too much superseded by those of Broussais. Dr. Gallup’s
views in relation to phthisis appear to us in this respect very just. He
considers the general state of the system, or the morbid habit as the pri-
mary and seminal element in that complex pathological condition constitu-
ting the disease.

Lest some of the above admissions should seem to any of our readers to
be inconsistent with the strong and earnest language that we haVe hereto-
fore made use of in deprecating all departure from the study of any thing
but the actual phenomena of disease, we will add that we go no further
than a rigorous and philosophical interpretation of all the phenomena will
safely bear us. And even here, we state the case only as a reasonable in-
terpretation of a series of facts, not as a fact itself — a probably correct
induction, not a necessary and demonstrated result. To this kind of rea-
soning we have no objection. In many instances we can hardly avoid
indulging in it. How is and why is this? are questions that will

intrude themselves at times into our presence, and wait there to be answered.
For instance, in phthisis, to which allusion has just been made, the
first, essential, legitimate objects of investigation are its phenomena, its
natural history — its hygiene and its therapeutics. Its causes, its signs,
the state of the organs, its prevention, its cure — these are the leading sub-
jects of our research, and they are to be ascertained, not from the physi-
ology of the body, not from any real or assumed knowledge of the inti-
mate properties and processes of the ultimate organization, but from the
simple, vigilant, long-continued study of actual appearances. Then there
are certain results that are inevitable, that flow, naturally, spontaneously,
from the data so obtained, and about which there will be no more contro-
versy or difference of opinion, than there is about the ascertained proper-
ties of inert mailer. Such are the influence of climate, season, locality,
age, sex, occupation; the symptoms, the lesions, the mortality, the effects
of medicine and regimen, and so on. All this constitutes the natural his-

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tory of the disease; and for the most part, and in relation to most diseases,
our self complacent boasting to the contrary notwithstanding, it is yet
very incomplete. After this is ascertained and settled, or during the pro
cess of its investigation, we may, if we choose, still in the spirit of a sound
philosophy, admit other inquiries, such as these; — what is the nature of
this morbid habit? what is the nature of this local lesion? what are their
mutual relations? which is cause, and which is effect? But let it be
ever remembered, that these matters are always to be kept in subordina-
tion to the first. They are to be deduced as more or less probable, only,
from the first and the only positive results. They are explanations of
facts, not facts. They are interpretations of appearances or phenomena,
not themselves appearances or phenomena. 'I'hey are legitimate hypothe-
ses, but they are not laws.

Above all things, let us understand that the practical rules which are to
guide our conduct in hygiene, diagnosis, prognosis and therapeutics are
to be drawn exclusively f^rom the former class of facts, never from the latter
interpretations and philosophizings. In the treatment of phthisis, we are
to be governed by the lessons of experience and not by our opinion of the
sthenic or asthenic, the local or constitutional character of the disease. In
the trial of new or modified processes of hygiene and therapeutics, we
may be influenced by these interpretations and opinions, if they have been
carefully and rigorously deduced, but they can do no more than to furnish
us with hints and suggestions. They give us no positive knowledge.
Broussais and Gallup regard phthisis as an inflammatory affection. One
of them looks upon it as a local, the other as essentially a general disease.
Louis does not believe it to be inflammatory in its nature; at least he de-
nies that there is any satisfactory evidence that it is so. Dr. Rush, Tully,
Miner, and others call it a disease of debility, and if the popular doctrine,
that our therapeutics must be rational, as the phrase goes, that is, that it
must be deduced from our pathology, be correct, and if each of these dis-
ciples of so many different schools, if each of these contradictory transla-
tors and interpreters of the same language, is consistent in his conduct, he
must treat the disease according to his own views of its nature, and in no
way else. Broussais must leech and blister the chest, Gallup must bleed
from the arm, while Rush, Tully and Miner must give bark, wine and
iron. Dr. Gallup indeed, while speaking of the importance of forming
correct opinions about the constitutional character of disease, expressly
declares, in the work before us, that “ those who are vascillaling in opin-
ion will always be the agents of mutable and inefficient treatment; whilst
those who embrace wrong theorems will \ise improper remedies?'' But
after all, exactly how far Dr. Gallup’s treatment is really based upon his
theorems it is somewhat difficult to say; and the same thing is true of the
whole class to which he belongs. Dr Miner, who may be considered, in
contiexion with Dr. Tully, the leader of a medical sect directly opposed
to that of Dr. Gallup, in almost every point of doctrine, and of practice,
is evidently enough, more or less governed in his therapeutics by his notions
of the nature of disease. A comparison of the opinions and practice of
these rival teachers would constitute a curious chapter in our medical his-
tory, and furnish, also, abundant and most apposite illustrations of the
subjects which we are now considering. Both, for instance, boldly assert
the curability, in their hands, of phthisis. Dr. Gallup says the disease is in-
flammatory, stlienic, no so dynamic, and that it can be removed only by
general bloodletting, emetics, external warmth, and so on, with this essen-

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tial condition, that all narcotics, and opium, especially, are withheld. Dr.
Miner says that calomel, opium and sanguinaria, with a suitable course of
mineral tonics are almost specific in its cure. In the hands of Dr. Gallup,
all our diseases are sthenic and are to be cured only by active, antiphlo-
gistic treatment. In the hands of his rival, they are all asthenic, and tonics,
stimulants and narcotics, with a scrupulous avoidance of the lancet, and of
all debilitants and refrigerants constitute the only true or safe method of
management. Dr. Gallup’s heroics are bloodletting, emetics and warmth.
Dr. Miner’s are calomel, opium, alcohol, capsicum, ammonia, arsenic,
phosphorus and blood root. Calomel and opium, says Dr. Miner, in acute
febrile diseases, are of greater service than all the other articles of the
Materia Medica. Both these articles, says Dr. Gallup, have been the occa-
sion of more injury than benefit. Bleeding and antimony are in the hands
of Dr. Gallup universal and all-powerful means of salvation to his patients,
“ The lancet,” says his rival, is a minute instrument of mighty mischief,
a weapon which annually slays more than the sword. “ Antimony
alone,” he continues “ does more injury than all the efficient exciting and
supporting agents of the Materia Medica. The king of Great Britain,
without doubt, loses every year more subjects by these means, than the
battle and campaign of Waterloo cost him, with all their glories.” Both
Dr. G. and Dr. M. appeal it is true, to the results of their treatment in
proof of its efficacy, and we are ready to admit what we really believe,
that the true grounds of their confidence in their respective modes of man-
agement are to be found, more than they themselves are aware of, in their
own experience. But, nevertheless, we can have no hesitation in saying
that their strong blind faith in exclusive and hypothetical systems of med-
ical philosophy has infused unsoundness and uncertainty into the only true
sources of all therapeutics. Even the great and sagacious Sydenham, although
he reversed the order of this vicious mode of reasoning, and deduced his
theory of disease from the observed effects of his methods of management,
was evidently influenced in his practice by his pathological speculations.
His notions of morbid action, after having been derived, in part at least,
from the apparent effects of remedies, reacted upon his therapeutics; they
dimmed the clearness of his perceptions, they warped his judgment, and
they acted unfavourably upon his practice.

Is it not clear, that in all these cases, that in all like cases, the whole
process of procedure is wrong? That such is our conviction needs now
hardly to be said. We have expressed this conviction at length, her»,
because Dr. Gallup’s book presents one of the most striking examples,
which the last hundred years have given us, of the philosophy and views
which we have been endeavouring to controvert. We have expressed our
convictions earnestly because we think them not only true and sound in
themselves, but of great practical importarice. If the Sydenhams, the
Gallups, the Tullys, the Miners, if the oracles and teachers in our temple
are not safe from the bad effects of their own false philosophies, how can
it be ex[)ected, that the great body of us, who are wont to look to them
and to their compeers for light, instruction and guidance, shall escape from
the same malign and disastrous influences?

We resume our analysis, and leaving the remaining three sections of
the subdivision of pathology, we come to that of etiology, to which one
hundred pages are devoted. This subdivision, taken as a whole, is written,
we think, with more straight forward sense and ability, than the preceding
portions of the volume, although it is far enough from being exempt from

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the kind of faults of which we have already spoken so freely. Many of onr
author’s views of the causes of disease are such as are generally received.
Others are somewhat peculiar to himself. In his twentieth section, of
more than twenty pages, he attempts to disprove the existence of any thing
like local miasmata or atmospheric contaminations, as causes of disease.
We have failed, however, to discover sufficient ground, either in the
author’s facts or arguments, for his denial of the existence of a deleterious
principle, acting within circumscribed limits, much as the more general
cause or principle, to which the term epidemic is applied, acts over more
extensive and wide spread regions. We do not see, that any very well
defined or cardinal difference has yet been shown to exist between these
two causes, the local miasmatic, and the more general epidemic. Dr. G.
thinks that many of the effects, which have been commonly attributed to
the decomposition of animal and vegetable matter, and to malaria, depend
solely upon sensible, meteorological inffuences. This is a fair subject of
discussion, but one in which it is not our intention now to engage. Dr. G.
admits the existence of a general, epidemic constitution of the air, or as he
calls it, a general atmospheric pestilent afflatus, and the intimation is
here again thrown out, that this invisible and mysterious agent of disease
and death, this inscrutable and terrific Unknown is only an excess of that
all pervading aura or entity of which we have before heard. Our author
has modified his views on this subject since the publication of his work on
epidemic diseases in 1815. He then referred ihis pestilent afflatus to some
electro-planetary operations, the nature of which is a good deal less intel-
ligible to ourselves, than he would then have had us suppose it was to him.
The electrical fluid, he then thought, “ was the vinculum, or connecting
medium of the fragments of universal nature, by whose pre-eminent powers
of attraction and repulsion, the planets were kept in their orbits, and per-
formed their revolutions, and by which even the comets w'ere recalled from
their distant wanderings, to revisit the sun, and to become visible to the in-
habitants of our earth.” This strange fluid, thus unceremoniously, with the
doctor’s aid, usurping the sceptre and dominion of gravitation, by the help
and co-operation of “ changes depending on the conjunction and opposition
of the planets,” kindled up, according to him, the pestilent afflatus. Such
was the doctrine of 1815: — Alas! that these systems of indigenous philo-
sophy should be so unstable and evanescent! The chain with which our
Dr. Webster essayed to bind together plagues, and pestilences, and eartl -
q;iakes and comets and volcanoes, proved to be of no adamantine materials.
Long ago, it snapped asunder, and all the multiform and appalling horrors,
all the gorgons and hydras and chimeras dire, which he had atter^pted to
fasten to it, in most unnatural and monstrous association, flew off’ again,
each to its own region, to render allegiance to its own sovereign and inde-
pendent laws. And then the learned and many tilled Dr. Mitchell’s doc-
trine of Septon, built up, as he fondly imagined, on the solid basis of
ancient lore and modern science, graced with the metaphorical drapery;
and embalmed in the artificial amber of Darwinian verse; that also is gone,
and now we find this electro-asirologic theory of Dr. Gallup’s, abandoned
and left to its early fate, even by its own author. Sic transit, etc.

Semeiotice, the last subdivision of the pathological portion of the work
occupies the first seventy pages of the second volume. When we say
that it treats of the phenomena of disease, and not of separate diseases, of
the morbid habit and not of any individual affection, we have said enough
to show how entirely destitute it must be of any practical value. It is not

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exactly correct, even, to say that it treats of the phenomena of disease. It
treats rather of the supposed philosophy or rationale of these phenomena,
and so far, is less useful, than it would have been, had it been confined
to a strict exposition of some of the generalities of morbid manifesta-
tions. Instead of making any analysis or commentaries, we will copy the
titles of the sub-sections of the first section, in the order in which they
stand, and also a page or two of the text. 'I’he titles are as follows; Pre-
liminary remarks: — Harmonies existing in disease: — Anomalies of the
phenomena: — Contingent phenomena: — Three series of phenomena: —
Reflections on the first series — predisposition: — Shrivelled aspect^ pale-
ness and faintness: — Chills and rigors: — Paroxysms^ and their period-
ical return: — Cold sweats: — Diarrhoea serosa: — Diabetes simplex: — In-
ordinate flow of bile: — Cardiac and arterial action: — Primary coma.

Under the last title, Dr. G. says, “ Primary coma arises from any cause
that suddenly occasions an exhaustion of vital force, by stimulation; or
from accumulations of blood in the venous radicles producing congestions
in the cerebrum, in which event the nervous force of the intellectual organs
is partially intercepted for a time. The same circumstances occurring in
the cerebellum occasion lassitude and paralysis; yet, if they should be of
an irritating kind, convulsions might attend. Even congestions in the'
cerebral tissues may induce the same results, when they are sufficient to
produce a perpendicular pressure on the cerebellum.”

In the following extract we have Dr. G’s views of the causes and nature
of the difference between the synochoid and the typhoid diathesis. We
hope, that in justice to themselves and to the author, our readers will study
this extract as faithfully as we ourselves have done, that they will coui--
prehend it as clearly, and that they will gather from it those rich lessons
of practical wisdom, which will enable them readily to distinguish between
a sthenic and an asthenic habit, and so to adapt with more accuracy and
certainty their course of treatment to the case before them,

“ In prosecuting the inquiry,” he says, “ we shall need to be reminded of
certain pathological theses, which are well established, and we shall, therefore,
not stop to prove them. One is, that every inordinate impression on the tissues,
if even through the mind, which is capable of altering the functions, is directly
followed by a retrocession of fluids from the surface to the central organs and
tissues. It is attended with aneemia externally, and hyperaemia internally.
This will hold good from syncope up to apoplexy. Although the period may
sometimes be very short, between the impression and the return of circulation in
quick responding habits, yet the change has existed in some degree.

“The principal physiological force existing, which must give energy to the
vascular tissues enabling them to restore the equilibrity to the surface, must be
the visceral ganglia and their nerves, since they accompany the arteries into their
dermoid capillaries.

“ Let us now recall wffiat has been amply proved, that early in every severe
disease the internal capillary vessels are fully distended, and engorged, whilst
anaemia exists on the surface. And, also, the physiological fact of the ganglia,
and their plexuses being vascular; together w’ith the pathological fact of these
ganglia being found engorged in the numerous examinations of fatal typhoid
cases, and the proposition appears to be established, that the derangements have
produced an inability in the capillary circulations, and this is the immediate
cause of the typhoid state. A similar derangement in the encephalon produces
coma, paralysis, and perhaps apoplexy, attended w'ith a failure of functions.

We have now found certain derangements in the circulations, sufficient to
No. XLVIII. — August, 1839. 33

386

Beviews*

account for the phenomena presented, and the circumstances which produce
these derangements have heretofore been amply discussed.

“We will, however, concede, that what has been advanced may be common,
in greater or less degree, to both the diatheses; and the inquiry must still be
extended, viz. What makes the difference]

“We assume it as a fact, that those cases which afford the clearest manifesta-
tions of a typhoid diathesis early show the most of an anaemic state of the sur-
face; and the inference must be, that these cases have the greatest burden of
internal hyperaemia also; and this is in conformity to autoptical inspections.

“ We improve, also, another fact, that the causes are more impressive under
some circumstances, than others; and, also, that they make greater impressions
on some less resisting subjects, than on others. ,

“ What has been advanced may not only be considered as facts, but as univer-
sally so. With this assurance, we will introduce another entitled to equal
credit; which is, the lively susceptibility of some temperaments enables the
tissues to respond more readily, and energetically, than others to every injury
offered them; and in disease severe stimulations have been presented. These
early responding actions restore circulation in some degree, both arterial and
venous, if not perfectly; and in sufficient season to save the paresis of the gan-
glia, which must take place, if the enthralments at the attack are continued.
The circulation w ill now be more free and intense, in proportion to the severity
of the impressions, and vascular force of individual idiosyncracy, if all other
things are equal.

“It is supposed this state of things may take place spontaneously, and without
the assistance of art, which is often the fact and'most generally so. The patho-
logical processes now go on exhibiting that train of phenomena, which indicates
the condition called the synochoid diathesis^ viz. heat, pain, redness, thirst, hard,
and often throbbing pulse, capillary circulation free, wakefulness, with liability
to delirium, fixed location with pain in some organ or tissue, blood on venesec-
tion quite florid, having a flbrinous crust, and cupped.

“ In analyzing the other limb of our subject, w'e merely need to make the rela-
tive inferences from the principles advanced. The blood is not early, restored to
the surface, either by nature or art, it is not aerated in the lungs, nor is venous
absorption excited sufficiently. The ganglial nervous force, including the
internal respiratory, is so far paralysed, and the tissues held in such rigid durance,
that the recuperative powers of the economy cannot be excited to afford season-
able aid; for, the primitive or first grade of vital energy of tissues holds the
nervous force in restraint by its acquired, or nosodynamic influence. It may be
held until all functional action ceases; but this is supposing an extreme case.
It most commonly falls out, that the responding impulses are drawn forth, but
in an imperfect manner, and this gives occasion to the typhoid state.

“The circulations, with all their relative associations, are but imperfectly per-
formed, when compared with the expanded state of the synochoid diathesis,
with arterialised blood. The congestive condition of capillaries internally and
externally still remains, at least in some considerable degree. The state of the
ganglial, or as combined with other nervous force constituting the nutritive
system, bears some resemblance to that of the encephalon in hemiplegia, half
active, half dormant. The circulations which do appear are wont to be irregular;
forcible in some organs, with heat; wffiilst in others coldness, and inactivity
exists. The same disparity is seen in the nervous functions of external relation;
plain specimens of ataxia. There exists uncommon prostration of muscular
powder, with sometimes spasmodic jerks; inability of mind, with coma-vigil;
pulse feeble, and frequent, say one hundred and twenty or one hundred and
forty in a minute; surface pale, or often dusky, sometimes with petechiae, vibi-
ces, &c., appearing, also, in the internal tissues; blood dark, and mostly desti-
tute of the fibrinous crust, and scarcely coagulating. This train indicates the
typhoid diathesis, in its highest degree; yet, it often appears with far milder
phenomena, p. 66—69.

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Gallup’s Outlines of the Institutes of Medicine,

After concluding what he has to say on semiotice our author presents ns
with a new' system of nosography adapted to his own views of disease.
We shall not trouble our readers with any accounts of this new entry for
the barren prizes of nosological distinction. That it will soon follow in
the multitudinous train of its defunct and departed predecessors, to an early
and unlamented exit, it requires no great foresight or sagacity to predict.
We shall pass by this portion of the work with the single remark, that
even if those systems of classification, which have been most generally
received, were less arbitrary and artificial in the principles of their con-
struction, than they are, there would still exist an obstacle in the way of
their correctness and completeness, wholly insurmountable. This obsta-
cle consists in our yet imperfect knowledge of the diseases themselves,
which are to be the subjects of nomenclature and arrangement. Almost
every individual disease is to be characterised, and must be defined, not by
some one peculiar element or phenomenon, but by the combination and
succession of all its elements or phenomena. This requires, that as an
indispensable preliminary to the location of a disease in any system of no-
sography, the whole natural history of the disease should first be ascer-
tained. This knowledge, we have just said, is still incomplete, and at the
time when tiie most celebrated and popular nosologies were framed, it was
exceedingly so. What other, than a provisional and temporary position,
could even Cullen and Good have assigned to those diseases which are
now most thoroughly and fully known? What means had they for
establishing the true places, and giving any thing like full definitions to
apoplexy, pleurisy, pericarditis, phthisis, and our typhoid fever, before the
researches of men now living had been made? We can have no sound
and permanent method of arrangement any sooner or any further, than we
ascertain the entire natural history of the several diseases, which are to
be the subjects of classification.

The remainder of the work, amounting to 274 pages, is devoted to thera-
peutics. Diseases, as they are considered under this head, are arranged
in four orders. In the first order are included synocha, phlegmasia dolens,
rheumatalgia, and all the simple phlegmasiae. This order, according to
Dr. Gallup, is made up of the diseases of the fibrous tissues. In the
second order, said to consist of diseases of the mucous tissues, are placed
synochus, catarrh and influenza, bastard peripneumony, phthisis, hooping
cough, and hemorrhages from mucous membranes. Order third professes
to embrace affections of the serous tissues, and the diseases enumerated
under it are typhoid fever, and dropsical effusions. Diseases of a com-
plex character, affecting many tissues, make up the fourth order. They
consist of the malignant epidemics.

Dr. G. states, in another place, that the diathesis depends upon the tis~
sual seat, as he calls it, of the morbid concentration. He says if the tissue
upon which the weight of the morbid habit primarily and chiefly falls be
the fibrous, that the diathesis will be of the pure synochal character; that
if the tissue be the mucous, the diathesis will be mild synochoid; that if
the tissue be the serous, tlie diathesis will be mild typhoid, and that if
many tissues are implicated, the diathesis will be grave, malignant typhoid.
The grounds of this generalization we must leave our readers to discover;
they are not stated by the author and they are wholly unknown to our-
selves.

We shall extract from this division of the work a few such portions as
may possess interest and value in themselves, and serve, at the same lime,

388

Reviews,

to exhibit to our readers the practical views of the author. We copy, in
detail, his treatment of what he calls synocha, and we do this because it
covers nearly the whole ground of his therapeutics. With some modifi-
cations it is adopted by Dr. Gallup in most of the diseases, which it has
fallen to his lot to manage.

“ If a patient is early visited, and before the repelling force has established
vascular action on the surface, then this ought to be encouraged by caloric
applied in some agreeable form. No method can be more useful than the warm
bath at a temperature of about 98° or 100° of Fah., but this should be accom-
modated to the patient’s feelings. This is often inconvenient and of slow pre-
paration. Then let the patient’s legs and arms be bathed in warm water; and
if not sufficiently warmed, as he lies in bed apply mild steam of water, more or
less, over the body, by processes well known. This is a preparatory process;
but care should be taken not to carry it to a great extent, especially if sweat does
not flow.

“If the sweat should be urged hard, and continued, there will be danger of
the capillary arteries forcing the blood into the interstitial spaces, and producing
lesions of circulation, occasioning petechiae, or at any rate sudamina, and attend-
ed with worse effects in the nervous tissues.

“ If the patient should be already hot, and skin dry before visited, then merely
bathing the legs and arms in warm water will be sufficient. In either event,
the first internal medicine except some mild aromatic infusions, will need to be
for an adult, about a grain and a half or two grains of tartarized antimony; or
about ten of the antimonial powder, or phosphate of antimony.

“The patient will be prepared for the next remedy in about an hour, after
taking the antimony; and then, unless, peradventure, there should be a free
sweat, and mitigation of pain, venesection should be practised. If this should
be the case, the sweat should be continued, and observation made how far it
may be relied on in affording relief. It is but seldom the sweats can be relied
on, even in a mild state of disease without blood-letting, and this we will next
consider.

“The previous measures have been directed, in order to produce as equal cir-
culation as may be obtained at this period; but still there may be much inequa-
lity until venesection is resorted to. We now take blood with the intention of
reducing, and even removing the nosodynamic state. We therefore say, this
remedy is debilitating under all circumstances; and if it is sometimes followed
by an increase of energy, it is because it relieves the organic impediments, and
emancipates their inability of function.

“ But, how much blood shall be taken in a severe case of synochal feverl
Shall we measure it? If we intend to arrest the chief force of the disease,
render it safe and manageable, or even palliate it at an after period, when it has
not progressed beyond the bleeding point, the only measure we want, is an
equivalent to the cardiac and vascular force. The rule must be to bleed to the
point of relief; and this implies a prostration of the nosodynamic force; and in
order to effect this, it is necessary, oftentimes to prostrate the physiological
energies. The more early and effectual the bleedings are practised, the sooner
the patient escapes the danger of the disease, and with the loss of the least
blood in the aggregate.

“In order for this remedy to be the most effectual, let the patient remain in his
warm bed, in a recumbent position; take from a vein intbe arm, in a full stream,
until the pulse falters, and the patient faints so far as to be unconscious of any-
thing, or to deliquium animi. He will no doubt revive, for we never knew it
otherwise. As the circulations resume their courses, by a convulsive effort of
' the recuperative powers, the nosodynamiais annihilated for the present, at least,
and the exhalations, absorptions, and secretions assume their natural courses.
Sweat flows, and now is the favourable time to continue it by mild and easy
measures; that is, continuing moderate external warmth, and aromatic infusions,
&c. Also, camphorated powders, or emulsion.

“This change is more certainly produced, if the patient should vomit at the

389

Gallup’s Outlines of the Institutes of Medicine.

moment of resuscitation, and the small dose of antimony was given about an
hour previous with a view in part, to this result.

“ I’he tokens of the primary cause having been removed, are, an immediate
flow of sweat from a previous dry surface; perhaps a change of countenance,
and cessation of distress and pain, with a milder pulse. The intention now is,
to prevent a return of the severity of the morbid condition; and for this purpose
mild sweating should be continued for twenty-four hours, unless pain, heat,
&c., should return. In this case sweating ceases. The morbid force has again
accumulated. It now becomes necessary, to repeat the bleeding, but without
intending to produce extreme faintness; but yet to the point of relief from
pain, &c.

“ The disease is liable to accumulate again and again, if it has obtained too
much fixity at the beginning, and must be early met by efficient remedies. The
bleedings should be repeated to the amount of relieving the urgency of the symp-
toms and rendering the case safe, but not now of suddenly arresting the disease.
When bleedings are early practised, they are well borne afterwards to a great
extent, if the necessity of the case should require them, and the bleeding point
is not soon passed by.

“ A case that has proceeded several days without bleeding, ought to be treated
very much in the same manner in order to render it more safe; for no further
time should be lost; provided, however, it has not proceeded beyond the bleed-
ing point. This is often one of the most difficult questions to decide. When
the question is rather doubtful in relation to copious bleeding, it should still be
practised, but in a reserved manner. It is often so, that the case cannot do well
without it, there being heat, pain, hard pulse, &c. still present. It may be pro-
per to take some blood from the arm, and some by leeches, and observe whether
it is well borne, and if so it may be repeated, and probably to the point of relief
and safety.

“ After fever has continued without bleeding, until there is evidently a failure
of vital energy, as manifested by many phenomena, bleedings are liable to di-
minish the recuperative powers, so that the patient loses the chances of a favour-
able crisis; or the chances may be diminished by it.. Yet, we have often known
decided benefits resulting from late bleedings, and in cases supposed to be very-
doubtful.

“ If the case should be attended with a determination to some of the organic
viscera, with local infiammation, bleeding should early be extended, in quick
succession, to the entire relief of pain, 'rhe repetitions should be practised as
soon as pain returns after being mitigated, and without delay. Organic changes
may take place within twenty-four hours after a re-accession of pain and inflam;-
mation, when it had appeared to be removed by previous means. So patients at
a distance should be provided with accommodations of relief, during the absence
of the medical adviser.

“ Considerable observation is necessary to enable the physician to use bleeding
to the greatest advantage. The patient should always be in a warm state when
it is practised. In any disease whatever, either acute or chronic, the case will
do better in the end as well as the time present, to take as much blood as is
necessary, along with the other aids of remedies, to remove effectually the mor-
bid habit, and without resorting to early tonics or stimulants. When this is
accomplished, the healthy actions never fail to replenish the system with sound
blood. It is the imperfect cures, or state of cachexy following disease imper-
fectly cured, that has given origin to the great complaints of Dr. Copland, and
others, arising from the loss of blood. Neither are subjects, that lose much
blood when necessary in disease, liable to suffer from plethora afterwards, if the
previous disease be fully eradicated. The salutary actions soon establish their
own healthy adjustments, when not interrupted.

“ As soon as the patient has an opportunity after the first process of treatment,
he should take a cathartic. According to circumstances, the first should be
more or less drastic. If the principal location of pain should be in the head, it
should be more drastic. Eight grains of calomel and rhubarb each may be suffi-

33*

390

Reviews,

dent. If the bowels are in a state of paresis, the case may require more, and
the intestines need to be the more acted on. But this is not commonly the fact
. in the affections under consideration. In ordinary cases the neutral salts will
be the best; and cathartics ought not to be so freely employed as to vellicate, or
produce excitation in the intestinal mucous tissue. Insynochal fever they require
to be repeated, usually about every other day.

“If the head remains affected with pain and heat after the bleedings, whilst
the lower extremities incline to be anaemic and cold, then the semicupium will
become useful. Instead of this, blankets may be wrung out of warm water, and
applied several thicknesses over the feet and up to the hips, and continued until
the parts become well warmed. This diverts the blood from the plus distended
parts to the exsanguious.

“ If there remains some pain of a part, as the epigastrium, or abdomen, apply
an emollient epithem. A handful of hop flowers infused in water, or spirit and
water, thickened with wheat bran makes a convenient application for this purpose;
it should be large and thick, as well as of an agreeable consistence. If much
coldness exists in a part, sprinkle it well with black pepper; this is better than
mustard, as it readily excites without blistering. If there is much heat of a
part that is pained, the epithem should be of an emollient kind.

“ After sufficient rounds of the above applications, if there should be found
tokens of some topical affection in a considerable degree internally, leeches, or
cups should be applied. Leeches to the hard and sensible parts, and cups to the
soft parts. It appears to be a fact, that after there has been a local affection
sometime established, the capillaries keep upTor a time an independent action;
or it may be slow of removal, and is greatly expedited by local bleeding. These
applications should be made early, or as soon as general bleedings have been
carried to a considerable extent.

“ Nothing hitherto has been suggested in relation to the fashionable practice
of blistering with cantharides; a practice we formerly went deep into, but now
think it not often necessary in fevers of high action.” * * *

“ Epispastics add severe, and oftentimes unprofitable stimulations to the gene-
ral system, as well as to the part. They ought to be avoided in every pyrectic
state attended with much heat. Nevertheless, there are circumstances in which
they may be useful, especially in protracted fevers. They should always be of
ulterior application. If after the general and local remedies, already suggested,
have been well employed, there should still be a local pain internally, of some
considerable importance, an epispastic may be effectual for its removal. * *

“ The practice of using opiate anodynes to mitigate pains in any form of fever,
and local inflammations, is greatly to be deprecated; it is not only unjustifiable,
but should be esteemed unpardonable; at least, after having heard a warning
voice. Whilst these are used no benefits can be obtained by the radical treat-
ment. In fevers of the synochoid character, the state of the diathesis may be
such, that a single ordinary dose may put the case out of the reach of all reme-
dies; and the greatest proportion by far of fevers of this climate, are of this
diathesis; neither are they scarcely more justifiable in the reputed typhoid habits.
Opium in all its modifications aggravates the morbid habit more than alcohol, or
any other of the higher stimulants.

“ The popular composition vulgarly called Dover’s powder, is used exten-
sively on the supposition, or pretence, of the hurtful effects of the opium being
altered, or neutralized by its other ingredients. There is no modification of
opium that alters its effects when given in a competent dose to affect the system.
The black drop, and morphia have very nearly, if not entirely the same effects
in stimulating the general system, in an adequate dose to ease pain, that the ex-
tract of opium has. These pretences are erroneous and delusive; for we have
seen the latter as certainly fatal as the tieute upas^ if not quite so speedily.

“ These articles may occasionally be used in some conditions of distress, of the
more strictly neuralgic kind, to much temporary benefit; also, a single dose at
the onset of severe dysentery, cholera and ataxic fever; but after even these dis-
eases have passed the stage pf extreme irregularity, they add greatly to the
danger; indeed, every condition of the established pyrectic habit is made worse

891

Gallup’s Outlines of the Institutes of Medicine,

by them, if not irremediable. It is probable, that for forty years past, opium,
and its preparations have done seven times the injury they have rendered benefit
on the great scale of the civilized world.” ^ *

“ During the progress of synochal fever, considerable advantage is gained by
small doses of some antimonial preparation, one given in the morning about 8
o’clock, and at about the same hour of the evening. The quantities ought to be
just sufficient to excite a slight nausea, and if there should be any thing in the
stomach that ought to be dislodged, it may excite emesis once or twice. If,
however, the dose should not be so great as to excite even nausea, it will have
a beneficial effect in promoting the secretions, and inducing composure. If we
are not greatly deceived, this article has many times produced a tranquillizing
effect in fever, so that the patient obtains more rest at night. It also favors an
easy and salutary crisis, by directing the efforts of the system to some of the
emunctories, as the skin, kidneys, or intestines, pp. 180—9

Phthisis as has already been said, is placed among diseases of the mu-
cous tissues, and fifty pages are set apart for its consideration. 'I'he doc-
tor re-asserts its curability, says nothing new of its causes, makes a blind
thrust at the stetlioscope, lays down some sensible prophylactic rules, and
devotes twenty pages to the subject of its management, wliich may be thus
briefly summed up. Let the patient live in a uniform temperature of about
75° Fah.; let him take, for one or two months, a warm bath, every night
or every other night before going to bed; in the early stage let there be a
pretty full bleeding which must be repeated at short intervals, persever-
ingly, whether the diathesis be synochoid or typhoid, till the morbid habit
is removed. Give an emetic of antimony or of ipecac, every day or two;
use demulcent drinks; after the pyrectic excitement is subdued, or when
there are excavations in the lungs, administer tonics cautiously, apply
counter-irritants to the chest, under the same circumstances; resort to agree-
able exercise, and, above all things, eschew opium. 'I'his latter condition
is insisted upon with so much emphasis, and constitutes so striking a pecu-
liarity in our author’s treatment, that we subjoin his opinions at length.
Speaking of narcotics he says,

“ We do not wish to stop and dwell on negative treatment: but as these are
recommended by even some late writers, and so much used, they are introduced
for the purpose of disapproval. From much observation of our own, we are
assured no progress can be made in the removal of constitutional pyrectic affec-
tion, whilst opiates, or any other narcotic is used. Every casPi in which they
have been used antecedently to the treatment, is sure t» be rendered more uncer-
tain, as respects a favourable reSuU; unless we may except digitalis in a limit-
ed manner.

“ The same remarks already made in relation to the use of narcotics in the
acute morbid habit, (Sec. xlvi. 1, i.) will apply in the chronic, and in an espe-
cial manner as relates to phthisis. We insist that no progress can be made in
the removal of the disease whilst narcotics are used in any form. We impute
the failures of those who have attempted the treatment of phthisis on some just
principles, in a great measure, to the use of these deleterious agents, so freely
intermingled with almost every other remedy. In part, however, in not having
just views of the character of the disease.

“We have, on several occasions, shown the illusions which have led to their
use; and we may now merely notice, that they are the highest stimulants ever
introduced into the materia medica. They retard the exhalations, absorptions
and secretions; render the tissues dry; afford a delusive truce to painful sensa-
tions, by diminishing the sensibility of external relation, and ultimately aggra-
vate every phenomena.

“ They co-operate with the remote and proximate causes of phthisis, and serve
to fix the primary changes in the inmost tissues more permanently, and render

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them more difficult of removal. Internal engorgements, or infarctions, are in-
creased by their use, even in small doses; and every post mortem examination
in subjects destroyed by narcotics, shows a violent state of congestion in the
internal tissues of the head, thorax, and abdomen, similar to those produced in
the internal tissues in the most malignant fevers.

“ It is an unfortunate circumstance, that those who have advised their use in
phthisis, have no better understood its pathological character, than the pro-
perties of these deleterious agents. There is something more than mere local
irritation in the former, and the latter are something besides soothing sedatives.
Many are more mistaken in these respects, than the deluded dram-drinker is in
conceiving that another alcoholic draught will surely do him good. Their sooth-
ing influences are quite as brief, and their sequences more certainly pernicious.

“We freely declare, if compelled to use laudanum, Dover’s powder, opiate
cordiale, or cough drops, &c., we would never attempt a radical cure of phthisis
pulmonalis in any of its varieties. In the last stage of a forlorn case, they are
more justifiable, in small doses; and yet a previous well conducted case will
hardly need them, as the calm composure of the downward way is commonly
disturbed by their use. In their omission, there is no running the risk of ex-
citing a repulsive delirium, or a forbidding lethargy.” pp. 282 — 4.

Departing from the rules which he had laid down for himself, and
impelled thereto, undoubtedly, by a full consciousness of the necessity of
sustaining his assertions by some positive evidence. Dr. Gallup reports
two cases, and we have a right to suppose the two strongest cases fur-
nished by his experience, illustrative of the efficacy of his mode of treat-
ment. The first is that of Dr. Gibson, who, after thirteen bleedings, so
far recovered his health, as to practise his profession some eighteen years,
at the end of which lime he is admitted to have died of phthisis. 'I'he
second is that of a lady supposed to have had the disease for twenty
years, who in the course of two years was bled twenty-eight times, and
who is still living. To any physician fully acquainted with the character
of phthisis, it is wholly unnecessary to say, that the occurrence of two
such cases, or of half a dozen such, during the lifetime of a practitioner,
has in it nothing at all unusual. In 114 cases reported by Louis, the
duration of the disease was, in one instance, ten years; in two, twelve
years; in one, fourteen years, and in one, twenty years. Sucli cases
have always been occasionally met with, but there is no evidence, what-
ever, that they are prolonged by bloodletting, or by any peculiar method
of management. Thq, fact itself, that the deposition and development of
the tubercular matter, and the progress of the disease, are in a few rare
instances suspended for a long period of lime, or entirely arrested, is well
established, but, unhappily, the causes which bring about this auspicious
result are not yet ascertained.

Under the third order, claiming to embrace diseases of the serous tissues,
we find typhoid fever. Dr. Gallup adds nothing to our knowledge of this
very common and important malady. His treatment of it consists in the
early use of the warm bath and of transient and diffusible stimuli inter-
nally; frequent emetics of ipecac.; occasional moderate doses of calomel
and rhubarb; moderate blood-letting; effervescing and refrigerant drinks,
and, in nearly all cases, an avoidance of opium.

The concluding portion of the work is taken up with the character and
treatment of the malignant ataxic diseases, among which are enumerated
typhus gravior, plague and yellow fever, cynanche maligna, epidemic
pneumonia, cholera, malignant dysentery and puerperal fever. Dr. Gal-
lup’s treatment of this class of c^iseases may be thus generally stated. In

393

Gallup’s Outlines of tlit Institutes of Medicine,

the first stage of oppression, heat is to be applied to every accessible part
of the body, external and internal, and light difiusible stimuli are also to,
be administered. As soon as the surface begins to grow warm, an anti-
nionial etnelic is to be given, and when by the use of these means any
considerable degree of reaction begins to manifest itself, the lancet is to be
resorted to, and used with freedom or reserve according to the peculiarities
of each individual case. Opium, and all the high and permanent stimuli
are to be scrupulously withheld.

We shall here close our notice of Dr. Gallup’s book. We have be-
stowed upon it that full and sober attention which its claims and character
appeared to us to demand. Of its peculiarities of style and grammar we
have said nothing. 'J’hese are matters of minor importance. We have
aimed to state its doctrines fairly, and in the expression of our own
opinions, while we have nothing extenuated, we have set down nought
in malice. We have quoted freely from the therapeutical portions of the
work, and so far as the author’s practical maxims and measures are the
result of observation and trial, and no farther, they are deserving of our
attention. But we are obliged to add that they must be received with
many allowances and with great caution, for reasons that have been
already given. We regret that this is so. We regret that the value even
of these better parts of the work before us is so much impaired by the
coloured and refracting media through which the author has witnessed all
morbid phenomena and all remedial processes. Dr. Gallup, with his
well known indomitable energy of character, and his untiring perse-
verance, and with the wide and rich field of observation, in which he has
passed a long and busy life, had he adopted a true method of investiga-
tion, and carried it out with that zeal and earnestness, which mark his
devotion to a false and profitless philosophy, might have now given to
the medical public a work of inestimable value. His most active and
vigorous years were spent among a hardy, temperate, and rural popula-
tion, in a region of remarkable general salubrity. His professional rides
have been, not through the narrow, and dark, and noisome lanes of some
huge metropolis, where poverty, and vice, and filth are huddled together
with wretchedness and disease, but over the green hill-tops, and along the
fresh clear livers of Vermont, amid scenes that might have brightened the
smile and gladdened the heart of Hygeia herself. But even here, where
every breeze seems laden with health, epidemic disease in many of its
most fearful and intractable shapes, has been but a too common visitant.
During Dr. Gallup’s residence here, dysentery, pleurisy, typhoid fever,
scarlatina and spotted fever were frequently and extensively prevalent in
their most malignant and destructive forms. A full and accurate history
of all the phenomena of these successive epidemics — of their varying
phases in different localities, and years, and seasons — of their symptoma-
tology — of the condition of the organs in the fatal cases — of their rate of
mortality — of the influence of age and sex, and of the effects of remedies,
derived from close, attentive and truth-seeking observation, would have
been welcomed by the profession of the present day with unmingled gra-
titude and delight. It would have been to medical science an invaluable
contribution and a source of lasting honour to its author. But this work
has not been done: it can now never be done: the materials for it are
irretrievably lost. And the same thing is true of most of the epidemics,
which have at one lime and another, devastated nearly all parts of the

394

Reviews.

world. They have been, for the most part; so imperfectly studied and
described, that we can now form only fvery indefinite and fragmentary
conceptions of their real character. Even the great work of Sydenham
on epidemic diseases constitutes no exception to these remarks. We
cannot now tell from his descriptions, whether his fevers are identical
with the typhoid of New England and Paris, with the petechial typhus
of Philadelpliia and Great Britain, or with neither of these diseases.
There is now but one true course for us. Leaving the past we must turn to
the future, and under the guidance of a better method, and in the spirit of
a sounder philosophy, begin anew the study of disease. The primordial
and ultimate affinities and actions of the living organism are wholly be-
yond the reach of our investigation. We must cease to build upon this
false and treacherous foundation, our theories of disease. We must cease
to speculate about those things which we cannot know. At least we
must cease to call this speculation, knowledge, to deduce from it our sys-
tems of pathology, and our indications of treatment. All this medical
transcendentalism we must abandon; and we must give in our hearty
allegiance to the simple, but stern requisitions of a rigorous and strictly
inductive philosoph}". In due season we shall reap bur reward. One
after another we shall find the established laws and relations of morbid
action naturally and spontaneously evolving themselves, the necessary and
inevitable fruits of our researches. Our therapeutic and hygienic indica-
tions will then become more determinate and settled, and the conjectural
act will be gradually conformed into one of fixed and positive rules.

E. B.

Article XII. — Outlines of the Principal Diseases of Females, chiefly
for the use of Students. By Fleetwood Churchill, M. D., Dublin,

1838, 8vo. pp. 402.

A FULL and accurate digest of the present state of our knowledge in
relation to the pathology and treatment of the diseases peculiar to the
female sex, is a work much wanted by the profession. Scarcely any class of
diseases have received more attention than these, or in the investigation
of which a greater amount of industry and talent have been engaged, and
yet, there are few perhaps, the nature and proper treatment of which are
less understood, or in which gross mistakes are more frequently made by
physicians of ordinary skill and experience.

This results from various causes; — On the one hand, from the extreme
obscurity of many of these affections, especially in their earlier stages;
causing the patient herself often to overlook them entirely, or more fre-
quently, to deceive herself as to their real character and location, and thus
inducing her, in connection with the promptings of a false delicacy, to
fnislead her medical adviser, if he be not fully on his guard, as to the
cause of the suffering and other morbid phenomena of which she com-
plains, by withholding from him, the very facts necessary to enable
him to arrive at a correct diagnosis and an effectual mode of treatment.
On the other hand, it arises, from much of the valuable information we
possess in reference to the diseases of females, being scattered through

Chiirchill’s Outlines of Diseases of Females, 395

various foreign periodicals, or, comprised in other works, but little accep-
table to the great mass of our profession. To the student and young
practitioner, especially, these affections are peculiarly perplexing.

To present, in a form adapted for their use, the pathological and therapeu-
tical facts, in relation to the maladies incident to the female sex, deduced
from the observations and experience of the most auihoritative physicians,
in different parts of the world, is the leading object of the work before us;
which, although the author claims for it no higher character than that of
simple outlines, compiled from the writings of others, with the addition of
“whatever information he may have acquired from hospital or dispensary
practice,” presents, nevertheless, a tolerably accurate, though concise
digest of the present state of medical knowledge, upon the subjects treated
of; which, while it is well adapted for the use of the junior, as vvell as
senior students, may, on many particulars, be consulted wdth profit by the
generality of young practitioners.

The arrangement adopted by Dr. Churchill in the present outlines, is a
somewhat unusual, though, in our opinion, a very judicious one.

The text contains a concise outline of the pathology and treatment of
each disease, without any detail of controversies or conflicting opinions,
which, whenever they appear of sufficient importance, are given in full,
in the notes appended to each page.

“ So that the junior student, by confining his attention to the text, may
acquire elementary information, which may be subsequently extended by con-
sulting the notes and references.

“ In the notes, likewise, will be found extracts from various authors when-
ever the support of their opinions seemed desirable.” “ Any remarkable and
authentic cases which bear upon the subject, have been also inserted, for the
double purpose of elucidation and description.”

The work is divided into two parts, the first treating of diseases of the
external genitals; the second, of those of the internal genitals, comprising
four sections devoted respectively to the affections of the vagina, uterus,
fallopian tubes and ovaries.

'J'he histories of the several diseases treated of, are, throughout, suffi-
ciently clear and accurate; of course, the more minute details, however
invaluable for the formation of a correct diagnosis, we are not to look for
in a work of mere outlines, like the one before us. The pathological
views detailed by the author, more especially in the second part of the
work, are, in general, those entertained by the most distinguished phy-
sicians; occasionally, however, vve are persuaded that a more minute
investigation of the facts upon record, would have induced him to reject
as altogether unsatisfactory, the views he has presented, while, in a few
instances, the vagueness of expression which characterises this portion of
the outlines, detract not a little from their merit and usefulness. The
remedial measures that have been found by experience to be best adapted
for the removal or amelioration of the maladies under consideration, are,
in most instances, clearly described-— although, in more than one instance
we notice important omissions under the head of treatment, and too often,
a use of general terms calculated to communicate no exact, and of course,
but little useful information to the student.

The first part of the outlines, as we have already remarked, treats of
the diseases of the external genitals, and is the least satisfactory of the two,
into which the work is divided. The subjects of the first four chapters,

396

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which are comprised in less than six pages, are phlegmonous inflamma-
tion of the external labia, encysted tumours of the labia, oozing tumour of
the labium, and warty tumours of the vulva. The fifth chapter, on itching
of the vulva, though more extended than the preceding, is altogether
unsatisfactory, and in some particulars, inaccurate. This affection, we
have found to be one of extremely frequent occurrence, and it is in most
cases, highly distressing to the patient. Of the condition of the vulva
and vagina in cases of pruritis, so accurately described by Dewees, no
notice whatever is taken. The author appears also to have followed
entirely those writers who have confounded this affection with furor
uterinus or nymphomania — a gross mistake, the source of which it is
difficult to understand, as the two affections may be readily distinguished
by an accurate observer; we have, ourselves, never seen them even occur
simultaneously. Dr. Churchill’s account of the causes of pruritis vaginae,
is extremely vague and conjectural; what is meant by “ the irregular dis-
turbance of the genital system,” which occurs about the cessation of the
menses, and is included by the author among the causes of pruritis, we
have puzzled ourselves in vain, to determine.

From the use of the several remedies recommended in this chapter, we
have seen very little or no benefit to result, with the exception, perhaps,
of the local application of cold water, frequently repeated. The remedies
that have with us most often succeeded in allaying the intolerable itching,
are a strong solution of borax as recommended by Dewees — a solution of
sulphate of copper, and a wash composed of a few drops of creasote
diffused in water. In very many cases, however, no one of the remedies
employed have succeeded in removing the disease, often not producing
even the slightest alleviation.

The ensuing chapter, on inflammation of the mucous membrane of the
vulva, is a very good one. The disease is often met with, especially in
infants, in regard to whom proper care has not been taken to keep the parts
perfect!}^ clean and dry; it is likewise of not unfrequent occurrence in older
children, and when overlooked or neglected by the parents in its earlier
stages, is apt to assume a chronic and very troublesome form. In these
cases we have not found the disease so invariably confined to the mucous
membrane of the vulva, as described by Dr. Churchill, but extending into
the vagina, and occasionally to the urethra, and then causing the utmost
distress to the patient whenever the urine is voided.

The two remaining chapters treat of enlargement of the clitoris, and
of tumors at the orifice of the urethra; they are sufficiently accurate.

Of the second part, the initial chapter treats of diseases of the vagina.

Vaginal leucorrhcea, which is first considered, the author refers, in
common with many, perhaps the majority of the most authoritative
writers, to inflammation, either acute or chronic, of the mucous membrane
of the vagina. In very many instances, there can be little doubt that the
disease is attributable to inflammation of that membrane; there, neverthe-
less, frequently occur, cases of leucorrhcea, in which the discharge is
very copious and difficult to arrest, and depending apparently upon an alte-
ration of tissue in the vaginal mucous membrane, in consequence of which
it secretes, instead of the ordinary mucus, a fluid morbid in its character
as well as in its amount, and unaccompanied by the slightest trace of
inflammation. This alteration of tissue, may, it is true, have been induced
by inflammation, but cannot, with propriety, be considered as being iden-

Churchill’s Outlines of Diseases of Females, 397

tical witli the latter in even its most chronic form. The fact is, that
notwithstanding all that has been written on the subject of leucorrhoea, we
are but little acquainted with its true pathology, and, in consequence, its
treatment is in a great measure empirical and uncertain. Its extreme
prevalence, and the very great inconvenience it almost always occasions to
those who are affected with it, demands that a greater degree of attention
should be paid, to acquire accurate views of its nature, leading to an
efficient plan for its prevention and cure. The remedies which the author
briefly enumerates, we have found in numerous cases to produce no bene-
ficial results, nor do we know of any that will be found more generally
successful.

The chapter on inflammation of the glandular structure of the mucous
membrane covering the cervix uteri, is derived almost entirely from
Clarke’s work on Diseases of Females.

As a very fair specimen of the author’s text, we present the whole of
the chapter on granular inflammation of the mucous membrane of the
cervix uteri — an important disease, which was, until recently, entirely
overlooked, and is still frequently confounded, by inexperienced practi-
tioners, with affections of a very different character.

“ As this is a disease which can only be discovered by ocular examination,
we could not expect to find any description of it in the older writers; but since
the adoption of the speculum as a means of investigation, this and other morbid
phenomena are much better known. The best, and indeed almost the only
account of it will be found in the valuable work of Boivin and Duges.

“ These granulations, which may be seen on the labia of the os uteri, and on
the external surface of the cervix, are the result of acute or chronic inflamma-
tion, and the two forms differ considerably.

“/n the first species^ or that resulting from acute inflammation, the granulations
are occasionally few in number, about the size of peas, sub-pediculated, firm
and whitish; more frequently, they are of the size of millet seed, whitish, but
soft, as if vesicular, in great numbers, and without a pedicle. The contact of
the speculum, or of the finger, or the act of defcecation merely, gives rise to a
discharge of blood from the membrane of the cervix uteri.

“ In the second species, the consequence of chronic inflammration, the granu-
lations are either small, hard and whitish — reddish and soft — or miliary, without
redness of the surface of the cervix uteri from which they grow.

“The usual symptoms are pain and vaginal discharge. In the acute form,
there is considerable redness, and vascularity of the parts, which bleed when
touched. In the chronic form, these two characteristics are absent.^ There is
some tenderness about the os uteri, with pruritis of the external parts, some-
times nearly causing nymphomania.

“ The causes are extremely obscure. In some cases, it appears to arise from
derangement of the catamenia, or from cold caught during menstruation or after
abortion; in others, it appears referrible to cutaneous or syphilitic disease. Not
unfrequently, it co-exists with induration or other organic change of the cervix.

“ The diagnosis^ with the aid of the speculum, is tolerably easy; but without
it, it will require great care and a sensitive touch, as the granulations, when
large, are generally soft, and when hard, are almost always very small.

“ The most successful consists in local bloodletting by cupping or

leeches' in the first instance, and in acute cases; followed by warm bath, emol-
lient vaginal injections, and counter-irritation.

“ In the chronic form, bleeding will rarely be necessary. Astringent or stim-
ulant injections will be found most efficient, especially a solution of the nitrate
of silver. Tonics (particularly the metallic) or mineral waters will generally be
found very useful.

“ Counter-irritation, by blisters on the sacrum or cauterization, will be found
No. XLVIII. August, 1839. 34

398

Reviews.

to exercise a decided influence over the progress of the disease. Should there
be an)^ suspicion of a syphilitic origin, specific remedies must be employed.
Every source of irritation should be carefully avoided.”

’^I'he chapter on thickening of the cellular membrane surrounding the
urethra, with a varicose state of the vessels, a disease frequently met with
in females who have borne several children, is condensed chiefly from the
work of Sir. C. M. Clarke.

The succeeding chapter on prolapse of the vagina is a very excellent
one, presenting a very full and satisfactory outline of the causes, symp-
toms and treatment of an affection by no means of uncommon occurrence,
and which from its being occasionally mistaken for prolapsus of the uterus
demands to be well understood, especially by the young physician that he
may be on his guard not to be led into an error of this kind. For a more
extended study of this affection the references in the notes will be found
useful.

Two short but interesting chapters on abscess between the vagina and
rectum, and on tumours in the pelvis external to the vaginal canal, close
this section.

Before proceeding to the consideration of the special diseases of the
uterus, which form the subject of tire next section, the author presents a
few very general observations on their pathology and diagnosis. These will
be found of great use to the student, especially the remarks on the modes
of investigating the existence, extent, and character of these diseases by a
manual or tactile examination, and by a visual examination by the specu-
lum. The following extract is offered as a specimen of the manner, in
which this subject is treated. We are prompted also to make the extract
from this the only correct plan of investigating the diseases of the uterus
being too often omitted entirely, or at least neglected in their first stages.

“ In all investigations into the symptoms of uterine disease, we should, first
of all, localise the complaint as far as possible, and then discover its effects upon
the different functions. The discharges should be carefully examined, and their
relation to the menstrual secretion ascertained, i. e. whether they occur about the
same time or during an interval, whether they increase or diminish before or
after the appearance of the catamenia, whether their colour varies from what is
usuall or, if they possess an offensive smell] if the discharge be sanguineous,
we should discover whether it commenced at a menstrual period] whether it is
accompanied by pain or bearing down] These points should all be cleared up
as far as possible, and even then there will often remain much that is doubtful.
But as if to compensate for the insufficiency of the ordinary symptoms, we are
possessed of other means of acquiring a knowledge of these complaints, which,
combined with what I have already noticed, will, in most cases, leave us with-
out excuse for any mistakes we may make. I allude to the power of making a
manual or tactile examination. The extent and accuracy of the information de-
rived from this source is very remarkable. By the ‘ toucher' we are enabled,
with considerable certainty, to decide the question of functional or organic dis-
ease. We can ascertain the degree of heat and moisture of the vaginal canal, the
character of any discharge, the state of the cervix and part of the body: we can
discover the presence of ulceration, of laceration, of displacements, with the exact
amount of the mischief: we can detect the existence of scirrhus, cancer, or of
morbid growth; by combining internal with abdominal examination we can
throw light upon the distinction between uterine enlargements and pregnancy or
ovarian disease. These and many other practical observations are the result of
this mode of investigation. The principal points to which our attention should
be directed when making the examination are; the state of the vaginal canal as
to calibre, heat, moisture and sensibility, the condition of the pelvic cavity,

399

Churchill’s Outlines of Diseases of Females.

whether unusually empty, or filled, and by what? the elevation of the os uteri,
its patency, sensibility, and integrity, the density of the cervix, its sensibility
and freedom from morbid growths or ulceration; the position and volume of the
womb, its mobility and sensibility. The nature of the discharge will be ob-
served on the withdrawal of the finger. If there be a breach of surface, its extent
should be ascertained and the coexistence of morbid deposition investigated. If
hemorrhage, the state of the fundus and cervix is of importance, and also the
existence of a fungous or polypous production. With regard to the two latter,
it will be proper to discover, if possible, their attachment, and to inquire as to the
possibility of their removal by ligature or excision.”

After some remarks on abdominal palpation and examination per rectum,
the author adds:

“ We have seen, that by the touch, in connexion with the local symptoms,
we can obtain information on all points, except that of colour, and the accuracy
of the knowledge so acquired, is scarcely, if at all, inferior to that obtained by
sight. It is very true, that a delicate sense of touch, and much experience is
necessary, before this degree of perfection will be obtained, but it is equally cer-
tain, that perseverance in availing ourselves of every opportunity (both on the
living and dead body) will ultimately be crowned with success. The only de-
ficiency in our means of diagnosis (viz., the not being able to examine the parts
by sight), has been supplied of late years by the introduction of the speculum^ and
to this we undoubtedly owe the extension of our knowledge of uterine and vag-
inal disease. Some new ones have been observed, and others already familiar
have been accurately described.”

The speculum “ enables us to detect variations from the natural colour of
the mucous membrane — slight erosions which might be passed over by the
finger, elevations on the cervix uteri, or on the walls of the vagina, too little
raised to impress the sense of touch. The length and thickness of the cervix
uteri, can be accurately ascertained, and we are able to discern the colour of the
surface of an ulcer. It will also confirm many other circumstances which have
been recognised by the ‘ toucher.^ In a practical point of view it is very valuable,
9.S enabling us to apply remedies (such as leeches, caustics, &c.) to the very part
affected, without injury to the neighbouring organs. On the other hand, we
must be careful that we do not mistake for morbid changes, those appearances
which are caused by the instrument itself. For instance, too much pressure may
alter the elevation and position of the uterus, and may produce a swelling and
puffiness of the cervix. The speculum should not be used at all when the
vagina is very tender.”

The notes to this preliminary chapter contain much useful matter.

In speaking of the catamenia the author seems to consider the opinion
of Mojon de Genes, that there exists no peculiar secreting apparatus for the
production of the menstrual fluid, as a hypothesis altogether untenable.
It is nevertheless the opinion of the best modern physiologists, founded
upon considerations which can scarcely be overturned, all secretions
are separated from the blood without the intervention of any peculiar se-
creting apparatus in the sense in which our author employs the term — that
they all take place by permeation through the coats of the blood vessels.

In the section which is devoted to tl>e disorders of the menstrual function
a very excellent outline is given of all the more important facts connected
with the subject. 'I’o treat, however, as the author has done, of each de-
rangement of this function as a disease, is in our opinion not calculated to
lead to correct practical views. To consider the disturbances to which
this function is liable in any other light than as phenomena dependent on
certain morbid, conditions with which the uterus itself is either directly or
indirectly affected, and to the removal of which our remedies are chiefly

400

Reviews.

to be directed is not only a very gross error in pathology but one very
liable to induce very serious mistakes in practice. The mere non-occur-
rence, suspension, irregular return or excess of the menstrual flux being in
itself of comparatively little importance in comparison with the cause
upon which it may happen to depend, nearly all our efforts directed to
restore the discharge when absent, to restrain it when too profuse, or to
cause it to recur at the proper periods, without a direct reference to the
morbid condition of the uterus or the other organs giving rise to the dis-
ordered menstruation, will either fail in the attainment of the desired
result or endanger the production of more serious injury than the mere
disturbance of function they are resorted to to remedy.

Chlorosis the author treats of as invariably arising from disturbance of
the menstrual flux, and lays down the first and most important indication
in its treatment to be the removal or mitigation of such disturbance. Now
it must be evident from a minute and cautious investigation of this disease,
that in the majority of instances the disturbance of the uterine function is
secondary to and dependent on the spinal disease, defective nutrition, and
anemia which give rise to the various groups of symptoms to which the
general denomination of chlorosis "has been given, and which occur, under
particular circumstances favourable to a deterioration of the general health
and vigour of the organism, as well in the male as in the female. Hence
the extreme folly and mischievous tendency of directing our attention pri-
marily and mainly to restore the regular performance of the menstrual
function, in the female, by remedies which are supposed to act directly
upon the uterus.

The Outlines, of the author, on the pathology and treatment of Dys-
rnenorrhosa, occupy ten pages, presenting a very ample summary of all
that is known in relation to this distressing affection. His chapter on
menorrhagia is also a very good one; we find very little of a controvertible
character in his account of either its pathology or therapeutics. We are
not prepared, however, to admit that the real menstrual discharge is very
frequently so profuse as to render necessary the adoption of any very
energetic remedies to moderate or restrain it. We believe that in every
instance menorrhagia, as it is termed, or a morbid discharge of blood from
the uterus, is a true hemorrhage, and invariably to be treated as such.

Some very judicious remarks are offered by Dr. Churchill in his chap-
ter on cessation of menstruation, which physicians will do well carefully
to attend to; for there sliU'exists a very erroneous notion as to the extremely
critical state of the health of females at this period, and the necessity of
subjecting them to a proper preventive treatment.

“The period of this great change (cessation of menstruation) is,” Dr. C.
remarks, “ about the age of 45 or 50; it is referred to by females as the ‘ time of
life,’ and is dreaded by them from a belief in its excessive mortality. This opin-
ion probably originated with medical practitioners; it is at all events, advanced
by the older writers.

“The mistake (for such it is) has probably arisen from comparing the mor-
tality of females at this period with that at any earlier period; comparing, in
fact, old and nearly worn out women with the young and strong. We should
expect the deaths among the former to preponderate* but this is no reason for

Even this would appear somewhat doubtful, for M. Constant Saucerotte has at-
tempted to prove by statistics, on a grand scale, that the mortality amongst women
is greater between the ages of 30 and 40 than between 40 and 60. Murct in his statis-

Churchill’s Outlines of Diseases of Females. 401

attributing- any peculiarly fatal influence to the subsidence of the uterine function.
We ought, in truth, to compare the mortality in the opposite sexes at the same
age, and we shall then arrive at a different conclusion.

“ M. Benoiston de Chateauneuf has recently shown, by extracts from burial
registries, that the mortality between the ages of 30 and 70 is not more consider-
able amongst women than men. But if the comparative mortality be less than
was supposed, there can be no question as to the importance of this period; for
in many cases, we find uterine and ovarian disorders dating from thence, and
we know that it is about this time generally that the more malignant diseases
commence. How far they may be owing to neglect at this period, it is very
difficult to say; we must suppose, how’ever, that the anatomical state in which,
the uterine system is left on the arrest of its function, must exert a certain amount
of influence in their production.”

Healthy women, the author very properly remarks, at this period, often
get much fatter, the abdomen and breasts enlarge, and they not unfre-
quenlly persuade themselves that they are pregnant.

“ Occasionally there seems to be a disposition to irregular distribution of
blood, local congestions, &c.; but more frequently the health is improved. This
is especially the case with those patients who have suffered much from dys-
menorrhea or irritable uterus. Delicate females, and especially those subject
to menstrual derangements previously, are exposed to local diseases of the sexual
system, and especially to that series of changes which issues in confirmed dis-
organization. This is the more to be apprehended if she have already been the
subject of uterine disease, or if at the time any such disease be latent, and on
our part it will require attentive examination and considerable practical skill.”

Ill the chapter on the constitutional effects of the disorders of menstrua-
tion the author has described a series of symptoms some of which are
no doubt immediately dependent upon derangement of this function, while
much the greater number, although they may very generally accompany
such derangement, we have room to believe, are improperly considered as
its effects; they depend evidently upon the same morbid condition of
certain organs to which the disorder of the uterine function is itself to be
attributed. This is especially true, as we have already remarked, of the
morbid phenomena constituting the disease denominated chlorosis.

In his account of the irritable uterus Dr. C. has followed Gooch almost
exclusively. Many important additional facts connected with this disease,
and the correction of some of the errors into which Gooch has been led,
the author might have derived from the works of Addison and Dewees and
the very interesting essay of M. Genet. As a means to assist our diagno-
sis, the pulsating, throbbing, or fluttering sensation within the vagina or
pelvic cavity, which according to Dewees, differing in degree, is an almost
invariable attendant upon irritable uterus and marks it in a special manner,
forms an all important item in the list of its symptoms.

The chapter on uterine leucorrhcea is full, clear and highly interesting;
and the same remark may be made in relation to the two succeeding chap-
ters on physometra or uterine tympanitis and on hydrometra or dropsy of
the womb, affections which though of not very unfrequent occurrence
have had very little attention paid to their pathology. By many we have
found even the possibility of their occurrence to be unsuspected. The
cliapter on mole^, &c., of the uterus presents a very instructive digest of

tics of tbe Pays du Vaud^ did not find between 40 and 50, a more critical age for
women than between 10 and :20. M. Lachaise in his medical topography of Paris, has
given similar evidence. Lisfranc^ Mai. del' Uterus^ p. 202.

34*

402

Reviews.

the principal facts in relation to their pathology, with copious references o
the several sources from which more detailed information may be derived.

'J'he student will find in the succeeding chapters of this section a very
able outline of the present state of our knowledge, in relation to the
remaining affections ol- the uterus. The best authorities have almost in
every instance been carefully consulted, and from their writings many
interesting extracts have been introduced into the notes appended to each
page: much valuable information may be derived, even by the practitioner,
from a perusal of this portion especially, of the Outlines.

In the very excellent chapter on prolapsus uteri, the author speaking
of the use of the pessary, and describing the various forms of the instru-
ment that have been recommended by the more distinguished writers on
this subject, remarks:

“ Various objections have, at different times, been made against the employ-
ment of pessaries, and latterly they have been repeated, and urged with all the
moral weight derived from long experience and high standing in the profession.

“ As far as I have seen, they may be arranged under the following heads:

“ 1. They are indelicate. — {Leake.')

“2. If too small, they will not rest in the passage, but be forced out, and
consequently do no good. — {Leake.)

“ 3. They irritate the vagina, and give rise to \Q\ic,ou\ieB'd..-^{Hamilton,)
especially if too large, {Leake, Murat.)

“4. They cause irritation, ulceration, and fungous growths. — {Murat. Annan.
Hamilton. Hieffenbach.)

“5. They give rise to putrid discharges from the vagina. — {Murat. JDieffen-
bach.)

“ 6. They occasion dilatation of the vagina. — {Dieffenbach.)

“ 7. They cause contraction of the same organ. — {Dieffenbach.)

“8. Patients have suffered under irritation of the bladder or constipation,
whilst using them. — {Dieffenbach.)

■“ 9. The pessary may become so incrusted with earthy matter, as to require
breaking before it could be extracted. — {Murat. Dieffenbach. Hamilton.)

“ 10. The pessary has been known to make its way through the walls of the
vagina, and into the rectum. — {Dieffenbach. Annan. Hamilton.)

“ With regard to the first objection, if true, the operation only shares equally
with all midwifery operations; nay, it is not a whit more indelicate than making
a vaginal examination. If the second or third objections be valid it must be
owing to an error in calculation, and if the operator be watchful, he will speedily
obviate it. The fourth, fifth, eighth, ninth and tenth are only applicable to
cases of gross neglect on the part of the patient or medical attendant, and cannot
for a moment be admitted as any argument against the proper use of the pessary.
As to the sixth and seventh, they cannot both apply to one case. Undoubtedly,
a pessary will keep that portion of the canal in which it is situated, in a state
of dilatation, but with equal certainty, the vaginal orifice will be relieved from
the distension caused by the prolapsed uterus, and if every time the pessary be
changed, one of a size smaller be introduced, it will be found quite adequate,
and in many cases, a permanent cure may, at length, be obtained.

“ With due respect, therefore, to the eminent authorities just quoted, their
arguments do not seem conclusive against the proper use of pessaries. On the
other hand, there is ample evidence from well authenticated facts, to show that
the judicious employment of these instruments, so far from being injurious, is
in many cases beneficial, and even preferable to any other plan of treatment.”

Dr. Churchill very properly notices the operation proposed by Mr.
Girardin, as a means of affording a more decided and permanent mode of
'relief in cases of prolapsus uteri, than that obtained from the best conr
structed pessary. It is an operation similar in principle to the oneadoptecl

Churchill’s Outlines of Diseases of Females. 403

for the cure of prolapsus ani by Hey and Dupuytren, and has been per-
formed with some modifications in Britain, by Doctors Marshall Hall,
Hemin^ ,and Ireland; in Germany by Professor Dielfenbach, Doctor
Fricke, &c., and in France by Velpeau and Berard. The author’s outline
of the facts in relation to this operation are sufficiently full, and his refer-
ence to authorities very complete.

An interesting chapter is given on the Diseases of the Fallopian tubes;
while the concluding section treats of the diseases of the ovaries — of the
leading facts in relation to the pathology and treatment of which, a very
complete digest is presented with copious notes and references. From
the very great obscurity of the majority of these affections, particularly in
their earlier stages — the slight amount of attention that has been paid to
their investigation — the difficulty if not impossibility of removing or
arresting them when they have eventuated in a change in the texture of
the organs, and our ignorance of the means proper for their prevention,
the present section of the Outlines is far less satifactory than either of the
preceding. This, however, is the fault of the subject — the author has
brought together the few facts known in relation to the ovarian diseases,
and future, more extended observations must be the means resorted to,
in order to supply, if possible, whatever is deficient in relation to these
affections, which are of more common occurrence than is generally sus-
pected.

The foregoing remarks will enable our readers to form a tolerably
just estimate of the plan and value of the work before us. We have not con-
sidered it either necessary or proper to enter into an extended review of it,
or to note each particular in which our own experience would lead us to
differ from the views advanced by the author, and the few instances in
which he has, in our opinion, failed in exhibiting an accurate digest of
all the facts known in relation to the subjects of which he treats — while
the extremely condensed form in which the valuable matter comprised in
these Outlines is presented, precludes any attempt at analysis.

As an introduction to the study of the principal diseases of females the
work will be found, we are persuaded, a very excellent and useful manual.
Even by the practitioner who is precluded by the want of the means or
the time from a frequent reference to the numerous standard works on the
affections peculiar to the female sex, it may be consulted with advantage.

There yet remains. Dr. Churchill remarks, two classes of the diseases
of females not included in the present volume, namely, those occurring
during gestation, and in childbed. These will form the subjects of another
volume, should the plan of the present one be approved. As this can
hardly fail to be the case, we may confidently expect the appearance of this
proposed extension of the Outlines. The diseases of pregnancy and child-
bed are, if possible, even more important than those of the unimpregnated
state, and in relation to which a vast amount of valuable information is
placed beyond the reach of the generality of students. D. F. C.

404

Reviews.

Article XIII. De V Mbumimirle ou Hydropsie causee par maladie des
Reins; modifications de r urine dans cet etat morbide, a Vipogue critique
des maladie aigucs et durant le cours de quelques affectioyis belieuses.
Par le Dr. Martin Solon, Medecin de I’Hopital Beaiijon, Agrege a
la Faculte de Paris, Professeiir parliculier de Maliere Medicale et de
Therapeutique, Membre de I’Academie Royale de Medicine, Chevalier
de la Legion d’Honneur. Avec planches coloriees. Paris: 1838.

Ofi Jllbuminuria or Dropsy caused by Disease of the Kidneys; of the altered
character of the urine in this disease^ and also at the crisis of acute
diseases and during the course of certain bilious affections. By Dr.
Martin Solon, Physician of the Hospital Beaiijon, &c. Paris, 1838.

The principal object of this uork is to advance our knowledge of the
affection commonly known as “Bright’s Disease of the Kidneys,” but
which our author calls “ albuminurie,” as being expressive of its principle
and pathognomic character, viz: the presence of a large quantity of albumen
in the urine. That the urine of certain dropsical patients contains albumen
is a fact which had been known long before the appearance of Dr. Bright’s
essays. In particular, Cruickshank and Blackall divided dropsies into
two great classes, according as they w’ere or were not accompanied by
albuminous urine. But it was reserved for Dr. Bright, of London, to esta-
blish the fact, that the kidney frequently becomes the seat of a peculiar
morbid alteration, from whence results the diseased secretion of the organ,
together with a certain train of morbid phenomena, of which a particular
form of dropsical effusion is the principal. Since the appearance of Dr.
Bright’s work in 1827, various essays upon the same subject, and con-
firmatory of his positions, have been published by some of the most eminent
physicians both of England and France, particularly Christison, Gregory,
and Rayer. The disease in question is said to be of frequent occurrence
in England, and we have no doubt that it will be found to be common in
this country also. Nearly half the cases of dropsy admitted into the Penn-
sylvania Hospital, in this city, during the months of July, August, Sep-
tember, and October, 1838, were characterized by albuminous urine in a
high degree. Our author’s history of “albuminurie” is founded upon
the reports of 28 cases of the disease, all of which are given in detail.
The most important questions appertaining to this affection are fully and
clearly discussed, and great caution and diffidence displayed in arriving at
positive conclusions. Appended to the essay is an inquiry into the condi-
tion of the urine under various circumstances where the kidney is not the
seat of Bright’s disease, and especially at the crisis of acute diseases.
Having premised this much, we shall proceed to a succinct analysis of the
contents of the work.

The urine of persons in health contains no albumen. In upwards of five
or six hundred trials, made by our author, of the urine of persons either
recently restored to health, or habitually healthy, no traces of it were dis-
covered, except for a short lime in two of them, where it was most pro-
bably accidental. Heat and nitric acid do not render healthy urine turbid,
but on the contrary clarify it when it is mixed wd.h mucus. Both these
agents, however, cause a coagulum in urine, which contains albumen even
in very minute proportions, and are consequently the tests especially relied
upon for the purpose of determining its presence. Of the two, the action of

405

Solon on filbuminuna or Dropsy,

heat is most to be depended on, as it occasions no change in the essential
elements of healthy urine. In making use of it, however, we must be
particularly careful that the urine is acid; if it is not so, it may easily be
rendered so by a few drops of acetic acid.

Besides the twenty-eight cases of Bright’s disease, our author reports
four cases of inflammation or haemorrhage of the kidneys. ‘ Of the twenty-
eight above mentioned, twelve died. All these cases are given in detail,
commencing with those which recovered. These are divided into several
series, the first of which includes six cases of acute hyperemia of the kid-
neys, which is regarded by Dr. S. as the first stage of the disease. The
second includes those more advanced, whilst the third contains the history
of a single case in which the disease was supposed to have arrived at its
third stage: — Then follow the fatal cases, accompanied in nearly every
instance by an account of the post-mortem appearances. We shall not
follow our author through these details, but proceed to the general results
in connection with the most important questions which he discusses.

“ We observe,” says our author, “ in reading the cases just detailed,
that there exists, in the affection called granular disease of Bright,, con-
stant and promiment symptoms, together with anatomical lesions which
are constant as regards their seat, but of various appearance. The symp-
toms are, albuminous urine, and dropsy in different degrees; the lesions,
are a morbid alteration of the kidney, which from simple hyperemia —
gradually passes to a peculiar state of yellow degeneration, &c.” p. 179.

These lesions and symptoms, as is afterwards shown, constitute one
and the same disease, which.he defines “ a special morbid condition of
the kidneys, occasioning the presence of albumen in the urine, and the
development of consecutive dropsies.”

Dr. M. objects to the term granular as used to designate it, since granu-
lations of the kidney are rarely met with in those who die. He likewise
objects to the term albuminous nephritis adopted by Rayer, because it
cuts short a question which is not completely settled, viz., the inflamma-
tory nature of the disease. Besides, as there are very striking points of
difference between it and nephritis properly so called, he thinks that the
adoption of the latter term may prevent some from recognising the dis-
ease—“ Thus,” he says, we expressed to a distinguished practitioner our
fear that a certain patient w’as affected with Bright’s disease. This, the
practitioner in question, acquainted with the term employed by Rayer, at
once denied, on the ground that the patient presented no symptoms of
nephritis.” p. 181.

The adoption of this term loo, he thinks, might give rise to the employ-
ment of antiphlogistic remedies, which are suited only, and that when mode-
rately employed, to the commencement of the disease, and not at all to its
more advanced stages. It may be objected to the term albuminurie em-
ployed by our author, that the symptom to which it refers occurs in other
diseases, to which he replies, that where albuminous urine is found in
nephritis or other acute affections, it is very far from presenting the same
characters which it does in Bright’s disease. In the latter, albumen is almost
the only principle contained in the urine, whereas in the former it exists
only in small quantity and without excluding the other elements of the
fluid. In the latter case too, albuminous urine is only of transient occur-
rence, and from this circumstance is readily distinguishable from the per^
manent albuminurie^ which belongs to Bright’^ disease, Whatever may

406

Reviews.

be said, however, in favor of this term, we cannot see any reasonable ob-
jection to continuing for the present, the use of the term Bright's disease,
or Bright's disease of the Kidneys, which has been very generally em-
ployed, not only in England and in this country, but we believe, also in
France. If at any future day, when the nature of the disease shall be
better understood, its affinity or identity with oiher pathological lesions
shall be shown, the adoption of a term to indicate such affinity or identity
would be liighly proper, in order to preserve a uniform nomenclature.

Post-mortem .Appearances. — Dr. S. found the kidney diseased in all
but two cases, where probably tlie presence of albumen in the urine was
owing to a derangement of nervous influence in one, and to the presence
of cysts in the kidney in the other. At any rate, they cannot invalidate
the testimony of the mass of cases which prove that a certain alteration of
the kidney causes a change in the character of its secretion, and deranges
the economy.

The morbid changes observed are classed \inder five different heads,
which, however, are reducible to three principle ones, viz., hyperemia,
yellow degeneration, other degenerations and accidental productions. In
the first, the kidneys may be merely found engorged with blood, but more
commonly are red, liypertrophied, heavier and larger than natural, the cor-
tical substance being the especial seat of the hypertrophy. In the second
variety, or that of yellow degeneration, the kidney is almost always en-
larged; the hypertrophy, when it exists, depending upon a development
of the cortical substance. Its external surface is of a very peculiar colour
which may be compared to that of the pancreas. Internally, it presents
the same colour, especially in the cortical substance, but as the disease
advances, the tubular portion is also involved and in some instances can-
not be distinguished from the other except by itS hjunuetl suniniil froni
which the urine may be made fo flovy, In the third variety, at the same
time that the kidney is the seat of the yellow degeneration, it assumes also
a granulated aspect, a form, however, which our author has rarely met
wiih, though frequently noticed by Dr. Bright, The kidney also may
become atrophied, whilst various accidental productions, as cysts, or tuber-
cles, may be developed in its substance.

Cawse-s.— Although adults are chiefly subject to the disease, children
are not altogether exempt-- contrary to the assertion of most authors, that
men are more subject to it than women, the latter were found more nume*
rous than the former amongst tlie cases recorded by our author. lie thinks
it possible that a moist and cold climate may favour its production, and
accounts in this way for the apparently greater prevalence of the disease
in England than in France. In the latter country too, it is more common in
the norlli than the south. In further support of this view he urges the fact
that many of his cases had been exposed to the influence of cold and mois-
ture. I know of no data by which to determine the comparative frequency
of the disease in this country, or even any one part of it. In the Penn-
sylvania Hospital, the writer examined a few months since, in conjunction
with Dr. Meigs the resident, the urine of all the patients in the men’s medical
wards, and of the whole number which was about twenty, found but three
in whom it was coagulated under the influence of heat and nitric acid — two of
these were undoubted cases of Bright’s disease, which was probably present
in the incipient stage in the third, in whom there was organic affection of
the heart, In a similar trial made upon a much larger number of patients in

407

Solon on JUbuminuria or Dropsy.

the wards of Gay’s Hospital by Dr. Bright, the number of patients with
decidedly albuminous urine was found to be about one in six, a rather
greater proportion than that found in the Pennsylvania Hospital. No
positive inference can of course be drawn from the above comparison as
regards the comparative frequency of the disease in this country and in
England, but it will serve to show that it is far from being a rare disease
amongst us, and consequently deserving of more of our attention than it
has hitherto received.

Of the influence of diet our author is able to say but little, but he thinks
that the habitual use of alcoholic drinks might oftentimes be regarded as
the principal cause of the disease. Disease of the heart may also be looked
upon as a predisposing cause, but not so phthisis, secondary syphilis, or
mercury. In particular, our author is satisfied that gravel or urinary calculi
have no influence in the production of this aflection, whilst, on the contrary,
they very strongly tend to the development of nephritis.

Symptoms. — The principal symptoms, as already mentioned, are albu-
minous urine and serous or cellular dropsy. Amongst the precursory
symptoms even, there is none more important than the presence of albu-
men in the urine, which may for a time exist alone, without any other
apparent disorder, and should induce us to fear the establishment of Bright’s
disease. In about one-third of the cases collected by our author, there
was pain in the lumbar region, in some of whom fresh pain was excited
by percussion on tlial part, but in all the others this mode of investigation
occasioned no painful sensation. In acute nephritis^ on the contrary, per-
cussion is almost always insupportable.

The emission of urine was painful in only one or two cases, and that
for a short time. Besides the presence of albumen, the urine presents
several other modifications; it is generally less dense than healthy urine;
its odour too is less marked, both when recent and after it has stood some
time in open vessels; its colour varies, but most commonly is very pale
and slightly turbid. When this last character is found united with infiltra-
tion of the limbs, it is of itself almost sufficient, says our author, to enable
us to say that the urine is albuminous. In every case of Bright’s disease,
w^hich has come under iny notice, the urine has presented the peculiar
characteristic aspect above alluded to. Urea exists in less proportion than
natural, and, when the yellow degeneration is complete, disappears almost
entirely, whilst the proportion of albumen becomes as great as possible.
In the majority of cases the heart was natural, and not disturbed in its
function; except, perhaps, in one case where there was vomiting. No
decided sympathetic disturbance of the digestive system was observed, and
diarrhoea was very rare. Habitual headach, followed ultimately by a coma-
tose condition, have been considered as common symptoms in Bright’s
disease, but our author did not observe them at all in the sixteen cases
which did not terminate fatally, and in only two of the twelve that died.

One of the most remarkable circumstances about the dropsy accompany-
ing this disease is, that cellular infiltration always precedes serous effusion.
This infiltration generally commences in the lower limbs, and the part
which is the seat of it offers considerable resistance to pressure. They
rarely, says Dr. S., acquire the size which is sometimes observed where
the infiltrat’on is owing to disease of the heart. My own limited observa-
tion does not accord with this assertion. In two cases which occurred last
summer at the Pennsylvania Hospital, the anasarca was very great, and in

408

Reviews,

one of them it was enormous, so that the skin in every part seemed to be
distended almost to its utmost limits. The dropsy is usually limited to the
cellular tissue, but sometimes it extends to the serous cavities. Thus in
eighteen of the twenty-eight cases under consideration, the anasarca was
simple, whilst in the remaining ten it was complicated with various serous
effusions; of these latter, ascites is the most common, and differs from that
following disease of the liver, &c., only in the less degree of distension of
the abdomen.

According to Dr. S., the disease presents itself both under an acute and
chronic form. When acute, it is very rapid in its course, and terminates
favourably if the patient is not carried off by some other disease. In others
its course is slower, the disease being as it were latent, and giving rise to
no other symptoms but albuminous urine, the existence of which is only
discovered accidentally; at a later period, infiltration of the limbs comes on;
here a part of the substance of the kidney is already altered in texture, but
the greater part is healthy; the urine contains only a small portion of albu-
men, and preserves most commonly its natural colour; urea and salts are
still found in it in considerable quantities. This condition may remain
stationary for some time, or may terminate favourably. The disease pro-
gressing, however, by the more extensive alteration of the kidney; the
urine becomes colourless and inodorous, gives an abundant albuminous
coagulum, and is only of the specific gravity of 1.004 or 1.008. Sometimes
the succession of symptoms does not take place as above stated, but the
disease is already far advanced before the patients are aware of its existence.

Diagnosis. — Whenever, in examining the urine of a dropsical patient,
we find an abundant coagulum constantly result from the application of
heat and nitric acid, we may affirm that the kidneys are probably the seat
of Bright’s disease. Some exceptions, however, occur, though rarely,
which may be distinguished, says Dr. S., by the following symptoms: —
“ The urine is habitually of a natural colour; it has preserved in part its
odour, and lost but little of its constituent principles; the amount of albumen
contained in it is slighti there exists some other cause, as disease of the
heart or liver for example, which accounts for the dropsy, <fec., &c. When,
on the contrary, the urine has lost its natural density and colour, when it
precipitates abundantly by nitric acid, or becomes turbid by the application
of heat, there is no longer any possible doubt; the dropsy depends upon
disease of the kidney, and not upon any other cause. Facts prove this
most conclusively.” pp. 241, 242.

As regards the distinction between Bright’s disease and nephritis, our
author observes, “ that Mr. Rayer thought he was establishing an impor-
tant difference between these affections, in giving to Bright’s disease the
name of albuminous nephritis. We do not assert that albumen exists in
the urine of all patients affected with nephritis;” * * *« but it

seems probable that it is so in most cases, for we can affirm that it presented
this character in the four patients attacked with acute or chronic nephritis,
the only ones which have come under our observation for several years.”
pp. 246, 247.

These facts are important, and should lead to further investigation. The
course of the disease, however, and the absence of oedema will readily dis-
tinguish nephritis from Bright’s disease.

Prognosis. — It will be recollected that of the twenty-eight cases reported

409

Solon on Albuminuria or Dropsy.

by our author, sixteen recovered; from whence it appears that the result
is not always so unfavourable as has been supposed by some.

Having described the character of the disease, our author goes on to
consider certain questions belonging to its pathology. As regards the
nature of the pathological alteration of the kidneys he says, “that what we
observe most frequently at the commencement of the disease would seem
to indicate the development of a peculiar irritation of the kidneys, under
the influence of personal predisposition and the afflux of blood.” This
hyperemia^ commencing in the cortical, and extending to the tubular sub-
stance, finally causes a modification in the nutrition of the organ, from
whence arise the various forms of degeneration which belong to the disease.
In two of the fatal cases, where death was occasioned by intercurrent affec-
tions, the kidneys presented this hyperemic condition without other change.
The six cases of a more or less acute character, which terminated favour-
ably, are referred to the same category. Without entering into a critical
examination of these cases, the interpretation of which certainly admits of
some doubt, we would merely observe that it seems to us unreasonable to
refer to an irritation, the first stage of a disease which, in a majority of
cases, does not present any of the characters which belong to such a state.
Thus in the majority of cases, according to Dr. S. himself, there is no
pain in the lumbar region, either spontaneously or by percussion. Even
when pains did exist, they were not acute, and disappeared quickly when
the disease became more severe; a circumstance very improbable if its
progress depended upon the increase of an irritation. That the disease is
very different from common inflammation our author himself admits, for
he says, p. 251, that “these affections have nothing else in common except
the fact of their being seated in the same organ.” Why refer them both then
to irritation, when in one the evidence of its existence is not to be found
in a majority of cases? Is it not as easy, and much more in accordance
with the facts, to suppose an alteration of nutrition independent of irritation,
or of which the latter may only be an accidental and occasional accom-
paniment?

The next question which our author discusses is, whether the albumi-
nous urine in Bright’s disease, is dependent upon the morbid alterations of
the kidney? A few cases are recorded in which very analogous symp-
toms have been observed, notwithstanding no such alteration of the kid-
ney was found; and during the course of some acute diseases it is certain
that the urine is sometimes albuminous for several days. These facts would
seem to show that the kidneys are not necessarily affected in every case of
Bright’s disease. In the instances above alluded to, however, the urine
does not present all the physical and chemical characters which it does in
Bright’s disease, nor does it contain albumen permanently, or in large
proportion. Besides, not a single w ell characterised case, according to our
author, has been adduced, in which the peculiar alteration in question of
the kidney, has existed without albuminous urine. We agree with him
then, in the justice of the conclusion, that the latter is dependent upon the
former.

Omitting the discussion of several other questions, we shall proceed at
once to give our author’s view of the treatment. He says:

“ Our results, based upon our own observations and those of others,
show that the resources of nature alone are insufficient to overcome the
No. XLVIII. — August, 1839. 35

410

Reviews.

disease, for it is owing oftentimes to its having been a long time left to
itself, that it becomes incurable.

“ Therapeuiics supplies us with some resources with which to combat
it. We may divide into two series the means which appear to us the most
proper to dissipate the two morbid conditions which we have observed, in
one of which there are the evidences of renal hyperemia, sub-inflammation
or latent inflammation, and in the other, of altered nutrition, organic dege-
neration and the development of accidental productions. In the first, the
medication will consist in the employment of sanguine depletion or anti-
phlogistics, together w'ith the use of diuretics and revulsives; and in the
second, in the continuation of diuretics and revulsives of a more active
character, but more especially in the prescription of various modifiers of
the nutrition, so well designated by the name of alterants, &c.” p. 276.

Of these remedies there are some which are suited to both forms, and
these are first spoken of.

In the early stages bleeding is very important, and often, according to
our author, exerts as powerful an influence in arresting the progress of the
disease as in overcoming an inflammation. At a later period, also, it is
somewhat serviceable, but in the advanced stage, is rarely productive of
any marked advantage.

Diuretics. — After remarking that in a healthy state of the kidneys, w^e
may employ indiscriminately almost any diuretic, he observes that, “ in
Bright’s disease where our object is not merely to procure diuresis, but to
modify the organic condition itself, the use of this species of medication
demands much greater precaution. We shall not obtain from diuretics,
which are in this case direct modifiers of the diseased organs, the desired
advantages, unless we have reference to the diseased condition of these
organs^ whether they are the seat of simple hyperemia, or of positive
change of structure. In the first, which constitutes the acute variety or
stage of the disease, mild diuretics will undoubtedly be preferable; in the
second, where the disease has passed into the chronic stage or form, the
stimulant or rather alterant diuretics may accomplish the desired indica-
tion.” p. 279.

Thus in the stage of hyperemia, he recommends acidulated drinks with
nitre, gum water, flaxseed tea, cream of tartar water, &c.” In cases
where the kidneys are less excitable, digitalis in powder, and especially in
infusion, also the infusion of horse-radish may be employed. These re-
medies, however, so useful in the early stages, exert but little influence
when the disease is more advanced. Here we must have recourse to sti-
mulant and tonic diuretics, and especially the squills, either alone or com-
bined with cdlomel, opium, &c., according to circumstances. The oxymel
and the bitter diuretic wine of La Charite, in which latter, it is combined
with several tonics, are preferred by our author, who thinks that these pre-
parations have been decidedly useful in cases where the disease was pass-
ing into the second stage. Various external revulsives should be em-
ployed, and especially the tartar emetic plaster.

Our author speaks very favourably of the action of purgatives, which
may produce a useful revulsion at the same time that they unload the cel-
lular tissue and serous cavities. He is not afraid of the inordinate irritation
of the intestines so much dreaded by some, and which he thinks is occa-
sioned in the hands of the English practitioners by the common admixture
of calomel with their purgative medicines. He prefers the hydragogue

411

Solon on Albuminuria or Dropsy.

cathartics, the least irritating of which, however, must be chosen and at
the same time cautiously managed. The oil of the Euphorbia laihyris,
and the juice of the root of the European elder are particularly recom-
mended. When the above remedies fail, alterants must be resorted to.
Of these mercury was chosen by our author. Instead of calomel “ which
so often produces salivation” he made use of mercurial ointment in
pills, which he thought less likely to cause the same effect; a drachm
of the ointment was generally combined with two seruples of medi-
cinal soap, sometimes a scruple of powdered squills, or of conium, and
three to six grains of extract of opium; the mass was then divided into
twenty-four pills, of which from one to three or more were taken in
the twenty-four hours. In three out of eight cases in which they were
tried, the symptoms entirely disappeared under their use. In two of the
five which were not benefitted, the disease appeared to be far advanced,
and in two others the great irritability of the mucous ntembrane of the
intestines prevented the continuance of the remedy. Having remarked,
that the above cases were too few in number to enable us to draw any
positive conclusion, he observes:

“ However, it is observable, that it was only when they produced sali-
vation or diarrhoea, that these pills were not efficacious, * * * ; that their
revulsive action was not advantageous, and that on the contrary, they were
really as useful, only where they acted as alterants.”

Having laid l^efore the reader a general view of the treatment employed,
we shall merely allude to one or two remaining observations upon minor
points of practice. When speaking of the necessity of employing reme-
dies for the purpose of relieving the patient from the inconvenient accumu-
lation of water in the serous cavities in cases where the renal disease is
far advanced. Dr. S. observes, that this condition of the kidneys prevents
our deriving much advantage from the use of diuretics, since the secretion
of urine rarely becomes so abundant as to occasion the disappearance of
thoracic and abdominal effusions. It would not be desirable indeed, he
thinks, that it should be abundant, as it would necessarily carry off a large
proportion of albumen. He prefers employing for the relief of the symp-
toms in question, hydragogue cathartics, which may, perhaps, at the same
time produce a favourable change in the kidneys themselves, by means of
their revulsion upon the intestinal canal. As the blood contains a larger
amount of water than natural, as well as less albumen, he recommends a
full diet, and to endeavour to give to the blood its proper stimulating and
plastic qualities, by means of ferruginous and bitter preparations. The
second part of the work before us, is occupied with the consideration of
the modifications of the urine at the critical period of acute diseases. In
the course of his experiments upon the urine in Bright’s disease, it be-
came an object to examine whether the fluid was not also coagulable under
other circumstances. The result was, that this property was found to
exist at the period of resolution of many acute diseases. This fact, he
thinks, as undoubtedly it is, of great importance in the study of the crisis
of these affections, 'i'he urine under these circumstances presents itself
to our notice under two difl'erent conditions.

1st. Where it coagulates or becomes turbid by the action of heat or
other agents, wnich is called “ coagulable wnne.”

2d. Where the same effect is produced by several reagents, especially

412

Reviews.

the acids, but where the matter precipitated differs essentially from the
first, since it is dissolved by heat. This urine is called precipitable.^^

In seventy-eight cases of acute disease, consisting of typhoid fever,
pleuro-pneumonia, &c., the urine was found coagulable by heat or precipi-
tated by nitric acid in sixty-two. The facts connected with most of these
cases are particularized, and many of them reported in detail. They seem
fully to establish the following conclusions drawn from them by our author,
viz:

“ That the urine becomes coagulable by heat, or precipitable by nitric
acid, during the course of acute diseases; that sometimes the phenomenon
shows itself at indeterminate periods, but is then but slightly marked; that
in some cases it does not occur, notwithstanding that the disease terminates
favourably; but that most commonly it shows itself towards the crisis of
acute affections, and indicates their favourable termination.” pp. 397, 398.

Of the sixty-two cases above mentioned, the urine was found coagulable
by heat in only twelve cases, whilst it was precipitable by nitric acid in
the remaining fifty. The fact of its coagulation by heat is sufficient proof
of the presence of albumen in the first series, but in these cases, neverthe-
less, the urine differed from that found in Bright’s disease, in containing
a larger proportion of saline or other principles. As regards the nature of
the precipitate formed by nitric acid, when the action of heat did not cause
a coagulum, our author, after a careful investigation of the subject, comes
to the conclusion: —

“ That critical precipitable urine owes its properties to an excess of
urea, uric acid and urate of ammonia.” p. 424.

The third part of the work contains the exposition of some facts relative
to the existence of the principles of the bile under certain circumstances in
several of the animal fluids, especially the blood and urine. The presence
of bile was indicated by the green tint produced by the addition of a few
drops of nitric acid to the fluid containing it. Besides this, other changes
of colour are sometimes produced, occurring in the form of zones. From
the facts brought forward, it would seem that the diffusion of the principles
of the bile in several of the animal fluids, particularly the blood and urine,
takes place at least under the three following circumstances:

1st. As a consequence of the production of tumours, &c., which impede
the passage of the bile into the intestines.

2d. As a consequence of inflammation of the liver or its appendages,
jaundiccj &c.

3d. In connection with the secretory disorder designated by the name of
bilious state'' by the older pathologists.

These results are highly interesting, and, if confirmed, will at least
afford an additional means of determining the existence of disorder of the
liver in cases where it would otherwise be very doubtful. T. S.

413

BIBLIOGRAPHICAL NOTICES.

Article XIV. The Elements of Materia Medica; Comprehending the Natural
History, Preparation, Properties, Composition, Effects, and Uses of Medicines^
Part I. Containing the General Action and Classif cation of Medicines, and the
Mineral Materia Medica. By Jonathan Pereira, F. R. S. and L. S. &c.
London: 1839.

The reputation of Mr. Pereira as a lecturer on Materia Medica and thorough
Pharmacologist had raised high expectations with the medical public in rela-
tion to the work which it was understood that he was preparing. Nor have
these expectations been disappointed by the part which has just made it®
appearance. We are acquainted with no treatise on Materia Medica, in the
English language, so full and at the same time so accurate as that of Mr. Pereira,,
so far as it has advanced. The volume now published, though confined exclu-
sively to inorganic substances, with some preliminary general observations upoR
medicines, contains upwards of five-hundred and fifty large and closely printeil
octavo pages; and the wmrk, if continued upon the same scale, will swell to three
times this magnitude. When it is considered that the style of Mr. Fereira is re-
markably simple and concise, and that no space is thrown away upon useless and
irrelevant speculation, it may be conceived, how abundant is the mass of materials
which he has collected. He treats fully of medicines in their relation both to
Pharmacy and Therapeutics, giving in detail an account of their origin, prepara-
tion, chemical properties and habitudes, sensible qualities, physiological effects,,
therapeutical applications, and modes of exhibition. The numerous reference*
to authorities, especially under the heads of the effects of medicines- upon th,@
system, and their uses in disease, prove at once the accuracy, of the autho¥ and
the great extent of his researches. His work is indeed rather a mine from which
teachers and succeeding writers may derive materials,, or a repository to whkh^
practitioners may occasionally resort for the supply of deficiencies, than a,
manual for students, who might be embarrassed by iis- abundance, and at, a lose
to decide upon the relative value of facts of whkhs they could, not retain the
whole.

In most of the treatises upon Materia Medica in the English language, there
is an evident want of a due balance between the department which treats of the-
mere physical properties and the preparation of medicines, and that which is
concerned with their direct application as therapeutical agents.. This arises;
probably from the great amplitude of the science, which renders it difficult to>
attain a thorough acquaintance with one of its sections without more or less
neglecting another. Thus he who has devoted to chemistry and the natural
sciences a degree of attention calculated to make him an eminent pharmaceutist,
is apt to be deficient in therapeutical experience; and the skilful practitioner
of medicine is not always the one most conversant with the physical properties
and preliminary management of the remedies which he employs. Writers par-
take of the same inequality of attainment; and their works not unfrequently
exhibit, in their partial elaborateness, the peculiar bias or partial qualification of
their authors. We have not this complaint to make against the work of Mr. Pe-
reira. He appears to have devoted an equal and full attention to the different
branches of his subject, and while he exhibits the somewhat rare qualities of a

35*

414

Bihlio graphical Notices,

good chemist and naturalist in his pharmaceutical descriptions, is not less
copious in the therapeutical department, although the absence of extended
theoretical disquisition in the latter, may give it more of a Doric air than is
exactly agreeable to eyes so much accustomed as those of medical readers in
general are to the ornaments of a Corinthian fancy.

If we have any fault to find with the treatise before us, it is in relation to the
plan of arrangement which has been adopted. Mr. Pereira divides medicines
into those furnished by the inorganic or mineral kingdom, and those which are
the result of organic or vital action. The former he classifies according to their
chemical composition, the latter, according to the position of the plant or animal
from which they are derived in the arrangements of the naturalists. This would
be the truest system of classification in a work of pure science, without any
especial practical bearing: but in a treatise intended for the guidance of the
medical practitioner or the instruction of the medical* student, the relation which
ought to serve as the basis of an arrangement is obviously that which is of
necessity most frequently present to the mind of the reader, and is best calcu-
lated to assist him in the future application of his knowledge. Such a relation,
in the present case, is that which medicines bear to the human system. A classi-
fication lounded upon their physiological effects is therefore most appropriate
in a treatise upon medicines considered in a therapeutical point of view, nor do
we altogether agree with Mr. Pereira, who, while he admits the superiority of
such an arrangement, could it be effected, deems our present knowledge of the
effects of medicines upon the system too uncertain to allow of a successful
classification upon this foundation. It is undoubtedly true that a precise know-
ledge of the physiological action of many medicines is yet wanting; nor is it by
any means certain that, were we in possession of such knowledge, a faultless
classification would be the result; for in this, as in most other departments,
nature has so distributed the properties of bodies, that, while the greater num-
ber are found capable of being associated in well defined categories, there are
always some which partake of the characters of different classes, and cannot
with propriety be arranged in any one exclusively. That an exact physiological
arrangement of medicines, therefore, cannot be effected, is no reason that this
plan should be entirely abandoned; as the defect is one which it shares with
all other systems, while none is equally efficient, in the present cases, for prac-
tical good. But Mr. Pereira, while he adopts the chemical and natural history
be^is of arrangement, when treating of individual medicines, has introduced
among his preliminary observations a physiological system of classification,
with general remarks upon each class, which will, in a considerable degree,
obviate the disadvantage to the student of the plan which he has pursued in the
body of the work.

In a brief notice like the present, it would be impossible to do justice to Mr.
Pereira’s treatise by extracting any portion of its contents, or giving an account
of its details. The general qualities which recommend it are copiousness,
fidelity, accuracy, and a singular neatness and perspicuity of style. Should it
be completed in the manner in which it has been commenced, it will fill up a
gap in English medical literature, of which those who are conversant with the
pharmacy and materia medicaof the continent have long been sensible. G. B. W.

Article XV. Prospetto Statistico-Clinico-Psichiatrico con Classificazione dei Reco~
verati nd Regio Manicomio di Torino. Del Dottore Cipriano Bertolini,
Medico Primario del pio Institute. 8vo. pp. 205, Turin, 1832.

Saggio di Statistica det Regio Manicomio di Torino, dal lo di gennaio 1831, a/ 31
Decembre, 1836. Del Dottore Gio. Stefano Bonacossa, Medico Assistente
di detto Manicomio. 8vo. pp. 127, Turin, 1837.

These two works afford a very complete and interesting statistical view of the
cases of insanity treated in the Royal Insane Hospital of Turin, during the six

415

Statistics of Royal Insane Hospital of Turin,

years and a half ending December 31st, 1836; exhibiting the number of the
patients of each sex received, discharged, and deceased during each month of that
period; the provinces from which they came, with the population of each pro-
vince; the respective ages of the patients; the number of married and single; the
species of derangement with which the patients of the different sexes, ages and
provinces were affected; the age and sex of the discharged and dead; the causes
of the several species of insanity in each sex, presented under several points of
view; the duration of each case to the period of cure of decease; the immediate
cause of death in those cases which terminated fatally, and meteorological obser-
vations for the period to which these statistics refer.

Besides the foregoing strictly statistical details, each of the works contains a
variety of interesting remarks in relation to the classification, pathology, and
treatment of the several forms of insanity; accompanied, in the first, by the
history of a number of cases with the autopsy of those which terminated in the
death of the patient; and, in the second, with a very full account of the Royal
Insane Institution of Turin, and ol its government and internal economy.

It must be evident that works of the character of those before us, scarcely
admit of review or of a satisfactory analysis. The more important pathological
and therapeutical remarks they embrace are so intimately connected with the
accompanying statistical details, as to be comparatively of little interest when
examined separately from them; while the chief value of the latter consists in
their minuteness.

We believe, however, that we shall be enabled to select, from the tables con-
tained in the essay of Dr. Bonacossa, some general facts interesting to such of our
readers as have turned their attention especially to the diseases of the mind.
Previously, however, to attempting this, it will be proper to present the defini-
tions given by that gentleman of the four species of mental derangement, which
he includes under the denomination Insanity; namely, mania^ dementia, mono-
mania, and lipemania. Mania he defines an exaggeration, an increased energy
of all or of the greater part of the intellectual faculties, and especially of the
memory, associated constantly with an excitement of the locomotive apparatus.
In this disease, a multitude of ideas, on indifferent subjects, are so rapidly and
with so much activity reproduced, that their regular and permanent association
is rendered impossible.

By dementia, he would express a derangement of the intellectual faculty, with-
out the expression of any particular passion; there being no longer a continued
and regular connection of ideas, whether from defect of memory or from a default
of the faculty on which depends the power to unite, and compare correctly those
ideas which recur to the mind.

By monomania, he understands an excessive activity of some instinctive
faculty united to a series of corresponding ideas.

By lipemania, (tristimania of Rush,) he denotes a moral condition in which
sad or mournful ideas predominate, with self discontent, and a character extremely
timid, hesitating, diffident, and superstitious.

The whole number of patients admitted into the Royal Insane Hospital of
Turin, from the 1st of January, 1831, to the 31st of December, 1836, was 1066;
namely, males 650, females 416; of these 538, namely, 400 males and 138
females, were unmarried, and 538, 250 males and 278 females, were married.

Of the 1066 patients, 966 (577 males and 389 females) were affected with the
different forms of insanity; namely, 256 (167 males and 89 females) with mania;
206 (133 males and 73 females) with dementia; 238 (127 males and 111 females)
with monomania; 266 (150 males and 116 females) with lipemania; whilQ 56
patients (41 males and 15 females) were affected with idiocy; and 44 (32 males
and 12 females) were affected with acute delirium.

The greatest number of the patients were admitted during the months of July,
August and September, namely, 342, or rather more than one-third; the smallest
number in January, 60: from the 1st of January to the 1st of April, the number
admitted was 204; from the 1st of September to the 1st of December, it was
249.

416

Bibliographical Notices,

The ages of the patients were as follows:

Under 5 years, 1 — a female.

Between 5 and 20 years, 49 — 31 males and 18 females.

20 and 30

((

272-

-176

((

30 and 40

((

342-

■213

((

129

40 and 50

222-

-119

((

103

((

50 and 60

104-

. 69

60 and 70

((

41—

- 27

((

70 and 80

((

. 1

((

Ages not indicated

28—

. 14

((

The largest number of patients were between 35 and 40 years, namely, 183,
(114 males, 69 females;) the next largest number were between 30 and 35 years,
viz: 159, (99 males, 60 females;) the next, between 25 and 30, viz: 151, (95
males, 56 females;) tbe next, between 40 and 45, viz: 127, (69 males, 58 females;)
the next, between 20 and 25, viz: 121, (81 males, 40 females;) the next, between
45 and 50, viz: 95, (50 males and 45 females.)

From tbe table showing the previous occupations and rank of the patients, no
very definite conclusions can be derived, unless we possessed a knowledge of the
proportion which each occupation and rank to which the patients belonged bears
to the entire population.

Selecting the largest numbers, as they appear in the table, we find of peasants
and persons from the country there were 428, (233 males and 195 females;) of
the military 69; of female servants 58; persons following a variety of occupations
55, (18 males, 37 females;) females engaged in domestic duties 44; shoemakers
37, (20 males, 17 females;) priests 20; persons of property 19; carpenters 16;
persons in office 14; masons 14; merchants 13; students 11; tailors 11; surgeons
10; coach-drivers 9.

Of 1045 of the cases admitted, in 646 (393 males, 253 females) the disease is
referred to physical causes, and 299 (164 males, 135 females) to moral causes.

Of the physical causes, 133 cases are referred to hereditary predisposition^
(80 males, 53 females:) Namely,

Mania. Dementia. Monomania. Lipemania. Idiocy. Delirium.
Males, 26 15 6 21 6 6

Females, 16 4 16 13 4 0

Total, 42

22 34

85 are referred to diseases and injuries of the head and brain, (57 males, 28

females:) Namely,

Mania.

Dementia.

Monomania. Lipemania.

Idiocy.

Delirium.

Males, 14

7 11

Females, 4

8 5

Total, 18

15 16

76 to the abuse of wine and ardent spirits, (73 males, 3 females:)

Namely,

Mania.

Dementia.

Monomania. Lipemania.

Idiocy.

Delirium.

Males, 26

12 13

Females, 1

1 1

Total, 27

13 14

35 to epilepsy, (30 males, 5 females:) Namely,

Mania.

Dementia.

Monomania. Lipemania.

Idiocy.

Males, 16

4 3

Females, 1

1 2

Total, 17

5 5

Statistics of Boyal Insane Hospital of Turin, 417

28 to the abuse of mercury^ (22 males, 6 females:) Namely,

Mania.

Dementia. Monomania.

Lipemania.

Males, 2

9 3

Females, 1

1 3

Total, 3

10 6

27 to disease of the abdominal viscera, (12 males, 15 females:) Namely,

Mania.

Dementia. Monomania.

Lipemania.

Delirium.

Males, 4

1 0

Females, 2

2 2

Total, 6

3 2

19 to insolation, (14 males, 5 females:) Namely,

Mania.

Dementia. Monomania.

Lipemania.

Delirium.

Males, 5

2 6

Females, 1

2 0

Total, 6

4 6

18 to syphilis, (11 males, 7 females:) Namely,

Mania.

Dementia. Monomania.

Lipemania.

Males, 1

8 1

Females, 3

1 3

Total, 4

9 4

15 to the suppression of various abnormal discharges^ (13 males, 2 females:)
Namely,

Mania.

Dementia.

Monomania.

Lipemania.

Idiocy.

Delirium.

Males, 2

Females, 0

Total, 2

14 to the abuse of venery and

onanism; all males: Namely,

Mania.

Dementia.

Monomania.

Lipemania.

Idiocy.

12 to diseases of the chest, (5 males, 7 females:) Namely,

Mania.

Dementia.

Monomania.

Lipemania. Idiocy.

Delirium.

Males, 2

Females, 0

Total, 2

12 to excessive fatigue, (10 males, 2 females:) Namely,

Mania.

Lipemania.

Idiocy.

Delirium.

Males, 2

Females, 0

Total, 2

54 to disorders of menstruation^ diseases of the uterus, and the accidents of preg-
nancy parturition, &c.: Namely,

Mania. Dementia. Monomania. Lipemania. Idiocy. Delirium.
14 2 16 17 1 4

418

Biglio graphical Notices,

Of the moral causes, 124 cases are referred to the disturbance of mind result-
ing iwm poverty and distress, (54 males, 70 females;) Namely,

Mania. Dementia. Monomania. Lipemania. Idiocy.

Males, 11 9 9 23 2

Females, 14 8 18 28 1

Total, 25 . 17 27 51 3

35 to love, (16 males, 19 females:) Namely,

Mania. Dementia. Monomania. Lipemania. Idiocy.

Males, 4 0 4 7 1

Females, 3 7 5 2 1

Total, 7 7 9 9 2

22 to domestic troubles, (17 males, 5 females:) Namely,

Mania. Dementia. Monomania. Lipemania.

Males, 2 2 3 10

Females, Oil 3

Total, 2 3 4 13

21 to religion, (12 males, 9 females:) Namely,

Mania. Dementia. Monomania. Lipemania. Idiocy.

Males, 2 2 5 2 1

Females, 1 0 7 0 0

Delirium.

Total, 3 2 12 2 1

19 io jealousy, (9 males, 10 females:) Namely,

Mania. Dementia. Monomania. Lipemania. Delirium.

Males, 1 3 2 3 0

Females, 1 4 0 4 1

Total, 2 7 2 7 1

18 to reverses of fortune, disgrace, (15 males, 3 females:) Namely,
Mania. Dementia. Monomania. Lipemania. Idiocy.
Males, 1 0 6 7 1

Females, 0 11 10

Total, 1 1 ' 7

17 to terror and fright, (8 males, 9 females:)
Dementia. Monomania. Lipemania.
Males, 0 4 4

Females, 14 4

Namely,

Total, 1 8 8

7 to protracted study — all males: Namely,

Mania. Dementia. Monomania. Lipemania.

12 2 2

Of the 1066 cases admitted in the institution during the six years and a half
to which the present statistics refer, there were within that time 466 (288 males,
178 females) discharged well, and 328 (188 males, 140 females) died.

Of those discharged well,

25, namely, 17 males and 8 females, were from 5 to 20 years old.

113, “ 70 “ 43 “ 20 to 30 “

Statistics of Royal Insane Hospital of Turin, 419

168, namely 101 males and 67 females were from 30 to 40 years of age.

Ill, “ 66 “ 45 “ 40 to 50 “

24, “ 16 “ 8 “ 50 to 60 “

23, “ 17 “ 6 “ 60 to 70 “

3, ' “ 2 “ 1 “ 70 to 80 “

1, a male over 80 years of age.

Of those who died^

9, viz: 5 males and 4 females, were from 5 to 20 years of age.

60,

((

20 to 30

((

78,

((

30 to 40

((

96,

((

40 to 50

47,

((

50 to 60

30,

((

60 to 70

((

70 to 80

1, a female was over 80 years of age.

With respect to the nature of the disease which was the immediate cause of
death in these cases, we are informed that

52 died from chronic spinitis.

n 130
n 10

86
37
18
18
86
37
n 160
n 13
n 86
n 260
n 130
32
13
52
18
37
10
65
65
21
18
50

meningo-arachnitis.
acute encephalitis,
encephalo-meningo-arachnitis.
chronic phlebitis,
cardio-arteritis.

consumption, or pneumonia with suppuration.

chronic pleuro-pneumonia.

acute pleuro-pneumonia.

chronic gastro-hepatitis.

acute hepatitis.

chronic gastro-enteritis.

chronic cystitis.

acute metritis.

chronic metritis.

dysentery.

diarrhoea,

ascites.

hydrothorax and hydropericardia,
hydrothorax.

hydrocephalus with meningitis,
scurvy.

tabes mensenterica.

serous apoplexy.

sanguineous apoplexy.

external surgical diseases. D. F. C.

Article XVI. — On the Nature and Treatment of the Diseases of the Heart; with
some new Views on the Physiology of the Circulation. By James Wardrop,
M. D. &c. Part I. 8vo. pp. 100. London: 1837.

The first part of Dr. Wardrop’s treatise, which is all of it that we have as
yet received, is devoted to preliminary observations on the structure and func-
tions of the heart, with which are interspersed some new physiological views on
the circulation.

In his investigations of the causes and treatment of the diseases of the heart,
Dr. W.’s attention was directed to certain symptoms with which various affec-
tions of that organ are accompanied, and, in seeking an explanation of them he
was led to reflect on several natural phenomena connected with the circulation

420

Bibliographical Notices,

of the blood in the heart, and with the function of respiration, but of which he
could find no satisfactory explanation; and to some of them even no allusion, in
physiological writings.

He was particularly struck with the influence of respiration on the action of
the heart, and with the influence of the latter on respiration, as well as with all
the modifications of these functions, not only in diseases, but likewise during
the acts of weeping — sobbing — crying — laughing — in the giddiness experienced
in turning round rapidly — in swinging, and in sea sickness.

“ His attention was not less arrested when contemplating the influence, which
the almost constant movements of the body exercise both on the respiratory and
the circulatory organs. He was led to inquire how the action of the heart and
lungs is increased by violent exercise — how persons can acquire by a process of
‘ training’ the power of using their muscles, until their muscular energy is ex-
hausted, without causing breathlessness or a sense of suffocation — in what the
art of diving consists — and finally, how diseases of the heart are caused by vio-
lent muscular exertions, and by mental excitement.

“ Having arrived at the conclusion, that these various phenomena are inti-
mately connected with the great function of the circulation of the blood, further
observations convinced the author, that each of these different acts is employed
for performing a specific purpose in the economy — some for increasing and others
for diminishing the quantity of blood within the thoracic cavity, according as
modifications in the quantity of the blood are required, or an adjustment becomes
necessary in different organs for the due performance of their respective functions.

“ In pursuing these investigations his mind was conducted, step by step, to
establish the existence of three important functions — functions connected with
the circulation of the blood which had hitherto been overlooked by physiologists.

“ First — That the muscles besides being the active organs of locomotion, per-
form the important office of increasing the quantity of arterial as well as of
venous blood, within the cavities of the heart.

“ Secondly — That the lungs regulate the supply of blood to the heart so as to
prevent congestion within the heart’s cavities, and

“ Thirdly — That the subcutaneous veins performing the office of a reservoir,
prevent congestion of blood within the pulmonary vessels.”

The author maintains that although it may be strictly true that the blood
flows in a circle, and that the heart, like a syringe, propels the sanguineous fluid
throughout the whole system, yet there are other physical conditions necessary
for the due performance of that important function — conditions to which we
must constantly refer in all our pathological researches. Every part of the body
requires a certain quantity of the blood to be sent to it, but it is indispensable,
also, that this supply be variously modified in relation to different organs. In
some it is requisite the supply be always equal and uniform, whilst, in others,
it is necessary that the quantity of the blood can be either diminished or in-
creased. Of the first of these conditions, there is an example in the brain, and
of the other, we have an illustration in the stomach, in which viscus, during the
process of digestion, the quantity of blood is more or less increased. Another
illustration of a temporary change in the quantity of blood in particular organs
is afforded in the erectile tissues.

“ The length of different arterial trunks — the diflferent angles at which the
branches leave the trunks — the varieties in the course or trajet of arteries — the
different modes in which they ramify — and the anastamoses of arteries, are,”
according to Dr. W. “ all peculiarities which are contrived to modify the circu-
lation of the blood in particular organs.”

The author is of opinion that the muscles, besides being the active organs of
motion, become essential auxiliaries iti the circulation of the blood, in both arte-
ries and veins, by the pressure which they produce during their contractions on
the adjacent vessels. This he denominates the musculo-cardiac function.

Whilst the pressure caused by muscles during their contraction, propels the
blood onwards in the contiguous veins. Dr. W. maintains, that the effect of
muscular contraction, both on arteries adjacent to, and those embedded in, the

421

Wardrop on Diseases of the Heart,

substance of muscles, must be to compress these vessels, and thus to impede
the flow of blood through them; hence, he remarks, the contraction of muscles
will increase the accumulation of blood within the heart in two ways — by acce/c-
ra/eng- the flow of the venous blood to the right heart, and by impeding the transit
of the arterial blood from the left heart.

While it appears not to be requisite that certain organs should be at all times
supplied with an equal quantity of blood, there are others wherein any alteration
in the supply of blood would be prejudicial, or even fatal, to the great functions
of life. Hence, whenever the heart requires an additional quantity of blood, this,
according to our author, is accomplished by impeding the flow of the arterial
blood through the arteries of those organs only which do not at all times require
a uniform supply of the sanguineous fluid.

“In accordance with these positions, we find,” he observes, “ that the arte-
ries of all organs of the first denomination are so placed that they must inevita-
bly be more or less compressed by the contractions of the adjacent muscles;
whilst the arteries of the other class of organs are so situated, that they are pro-
tected from all pressure from the movements of the muscles contiguous to
them.”

Of the first of these conditions we have an example in the arteries of the
limbs, and of the second, in the arteries of the brain, heart, stomach and iris.

Arteries accompany the veins where it is intended that both the systems of
vessels shall be influenced by muscular contractions — while those vessels which
are not liable to compression from the contraction of muscles are not similarly
disposed, either with relation to the muscles, or to each other — thus in the in-
ternal viscera, such as in the brain, lungs, and liver, the veins do not accom-
pany the arteries.

The involuntary muscles perform agreeably to the views of Dr. W. an
equally important share in modifying the circulation of the blood.

“ The vermicular motions of the stomach and intestines during the process of
digestion, must doubtless,” he remarks, “ have a very considerable influence on
the circulation of the blood, both in the veins and in the arteries of these organs,
and hence, during the movements of the alimentary canal, we observe an in-
crease in the frequency of the pulse.”

In regard to the influence which the respiratory organs exercise on the ac-
tion of the heart, and the share they have in carrying on the great function of
the circulation of the blood. By whatever powers, the author remarks, the
venous blood reaches the two venae cavae, the act of inspiration assists in bring-
ing the venous blood into the right heart— it also assists the circulation of the
blood in the pulmonary arteries; the expansion of the lungs accelerating the
ingress of the venous blood into the pulmonary arteries, and also permitting the
arterialized blood to flow readily through the pulmonary veins. t>\nmg expira-
tion^ the collapse of the lungs and the subsidence of the parietes of the chest
and abdomen, aid by their pressure the transmission of the arterial blood from
the lungs into the left heart, and also assist in propelling the blood along the
large arteries, at the same time impeding the current of blood coming from the
right ventricle into the pulmonary artery.

“Inspiration may be therefore considered as accessory to the venous^ and expi-
ration to the arterial circulation, the one aiding the heart like a sucking, and the
other like a forcing pump.”

“ Besides these two important offices of the respiratory apparatus connected
with the circulation of the blood, both of which may be considered as altogether
depending on changes in the form and capacity of the thoracic cavities, there is
a third, and as Dr. W. has endeavored to show, accessory function which is per-
formed by the lungs themselves, the pulmonary vessels serving as a receptacu-
lum or reservoir for receiving any surplus quantity of blood whether venous or
arterial which the cavities of the heart cannot admit.”

In order to distinguish this function from all the others performed by the
respiratory apparatus. Dr. W. denominates it t\\e pulmo-cardiac function.

“ Whenever,” he remarks, “ from any cause the systemic blood cannot find a
No. XLVIII. — August, 1839. 36

422 Bibliographical Notices,

ready exit from the left ventricle, and when, at the same moment, there is no
diminution in the supply of venous blood to the right heart an accumulation or
congestion of blood must then take place within the cavities of the heart, and
therefore, in order to prevent such undue accumulation, the effects of which
would be more or less injurious, further means become requisite, besides the
expansive power of the parietes of the chest.”

“ If there be only a slight increase in the quantity of blood within the heart,
such additional stimulus by increasing the vigor of the heart’s movements, may
along with the elastic quality of the fibro-cartilaginous portion of its structure,
which is placed at the roots of the large vessels, be alone sufficient to equalize
the circulation. But if the increased supply of blood to the heart be so conside-
rable that the surplus quantity cannot be received within its cavities, the lungs
are then required to lend their assistance.” — “ The pulmonary vessels being
imbedded in a soft and yielding substance, are susceptible of various degrees of
distension, so that they readily give way for the reception of any surplus quan-
tity, whether of venous or of arterial blood, and retain it until it can be received
within the heart.”

But whilst the pulmo-cardiac function is in the opinion of Dr. W. employed
to relieve the heart of any surplus quantity of blood which it cannot receive
into its cavities, he ascribes to the subcutaneous veins, which being placed
externally to the fascias are not affected by the action of the muscles, the office
of relieving the pulmonary vessels of any superabundant blood which they are
not capable of receiving without interruption to the great function of respiration.

The chain of reasoning employed by Dr. W. in sustaining the peculiar views
in relation to the circulation of which a hasty sketch has been given above, is
extremely plausible, if not entirely conclusive — while the illustrations he intro-
duces from various well known physiological and pathological phenomena ren-
der these preliminary observations to his proposed treatise on the diseases of
the heart and their treatment one of an extremely interesting character.

D. F. C.

Article XVII. — Isagogdtnn Doctrinam Morborum Chronicorum, Audore Ger.

CoNV. Bern. Suringar, Medicinoe, Chirurgiae et artis obstetric, Doctore,
et medicinae practicae in Schola Clinica et in illustri Amstelodamensium
Athenaeo, Professore. 8vo. 2 yols. pp. 210 — 250. Amsterdam, 1837.
Introdudion to the Study of Chronic Diseases. By G. C. B. Suringar, M. D.
Professor of the practice of medicine in the Clinical School and Atheneum of
Amsterdam.

Under the denomination of chronic diseases, the author of these volumes
comprises all those affections of which neither acute inflammation nor fever forms
a part of the essential or prominent phenomena. Among these diseases are in-
cluded, as will be perceived, some of the most important to which the human
frame is subject, and with the pathology and treatment of which, notwithstand-
ing the very close attention that has been paid to their investigation, more espe-
cially of late years, we are still but very imperfectly acquainted.

To furnish to the student a concise manual of the general facts connected with
this interesting and important class of maladies appears to have been the lead-
ing object of Professor Suringar in the preparation of the volumes before us.
Considered in this light, deficient as they are in many particulars, they consti-
tute certainly a very useful work — forming an excellent introduction to the
study of those more extensive treatises on the subjects of which they treat, for
which we are indebted to the industry and talents of some of the most distin-
guished members of our profession.

Professor Suringar divides the chronic diseases into two classes; namely,
1, those of organic life; and 2, those of animal life. Each of these classes is
subdivided into three sections.

423

Dunnel’s Annual Report.

The sections of class I. embrace

1. Those chronic affections attended with lesions of the blood-vessels and of
the blood. Chronic congestion and inflammation, haemorrhage, chlorosis, cya-
nosis, scurvy, purpura haemorrhagica, ulcus noma.

2. The chronic affections of the digestive, respiratory, secretory, excretory,
and nutritive organs.

3. The chronic affections of the reproductive organs.

The sections of class II. embrace

1. The chronic affections of the apparatus of motion. Gout, rheumatism.

2. The chronic affections of the organs of sensaiion. Hypochondriasis, hys-
teria— the neuralgiae — the lesions of the external senses — the various spasmodic
and convulsive affections — atony — paralysis — apoplexy — asphyxia.

3. The affections of the mind, or vesaniae.

In his brief sketch of the symptoms, diagnosis, causes, and treatment of the
several chronic affections embraced in the foregoing classification, the author
has, in general, exhibited sufficient clearness and accuracy. He has evidently
collated with care the more recent observations in relation to their pathology,
and is familiar with the improvements which a more intimate acquaintance
with the true character of these diseases, has been the means of introducing in
reference to their therapeutics. He has, nevertheless, not unfrequently adopted
the statements and opinions of the older writers, that subsequent and more
extended observations have shown to be erroneous, or at least, of doubtful
authority. To the history of each disease is appended a short list of the best
writers, who have treated of it, with the title of their works, which, though
incomplete, is not without its value.

There is no part of the work of Professor Suringar which calls for any par-
ticular notice, or which would warrant a formal review. The chief merit of an
elementary treatise, such as it alone professes to be, consists in its presenting a
well defined and correct outline of the subjects of which it treats, leaving to the
student, the labour of filling up that outline with the materials subsequently
derived from the various sources placed within his reach. This particular merit
the volume before us possesses, and we feel a pleasure in recommending it as a
useful introduction to the study of those affections to which the author has
extended the term chronic. D. F. C,

Article XVIII. Annual Report of the Interments in the city and county of New
York for the Year 1838, vnth accompanying Remarks. By Henry G. Dunnel,
City Inspector. New York, 1839.

This little pamphlet of some twenty pages, reflects great credit upon Dr.
Dunnel for the ingenuity displayed in exhibiting the annual mortality of a large
population in such a manner as to show at a glance many of the most interesting
details and results, to obtain which from tli-e ordinary bills of mortality would
have been in many cases absolutely impossible, and in others a matter of no
little calculation. The tabular form exhibits the number of deaths from each
particular disease or source of mortality, with the ages, sex, colour and place of
nativity of the deceased. The diseases are classified beginning with “ Diseases
of the Brain and Nervous System^’’’* and proceeding successively through the list.
The total mortality reported from the first of January to the last day of December,
1838, is 8053, of which there were of white males 4090, females 3287; black
males 336, females 340. We subjoin Dr. Dunnel’s “Remarks,” which will be
found highly interesting by those who take an interest in such statistical subjects.

“ By this report it will be seen that the deaths in 1838 were 679 less than in
1837. Precisely the increase of 1837 over 1836.

“ It may be well, for the gratification of those who have not the time or taste
to enter into the investigation, to subjoin a running commentary upon some of
th-e details herein presented.

424 Bibliographical Notices.

“ There are several interesting results to be gleaned from the precise and pecu-
liar mode of arranging these tables, and which could not be shown by any other
method.

“ Leaving others to account for the causes, while the facts are simply placed
before them, I will premise that, while the total of deaths has been 679 less,
the variation in prevalency of different diseases has been immense; from a
decreased mortality of 1654 upon some, to an increase of others of 1209.

“The decrease has been chiefly upon the following diseases, viz: of Scarlet Fe-
ver, 322; Typhus, 234; Consumption, 233; Convulsions, 178; Measles, 159; Small
Pox, 79; Fever, 74; Teething, 96; Inflammation of the Chest, 40; Diarrhoea, 30;
Drunkenness and Delirium Tremens, 31; Childbed, and Puerperal Fever, 24;
Dropsy, 19; Bleeding, 12; Mortification, 10; Old Age, 8; and Epilepsy, 5; and
28 less were drowned.

“ Of the diseases that have increased, the following stand most conspicuous:
of Cholera Infantum, 184. More deaths of this disease occurred this year than
ever before, with the single exception of the cholera year, 1834, when it was
only 38 greater. In the year 1832, it was 103 less than in this. The increase
of Marasmus is 178; Hooping cough, 156; Unknown, 102; Apoplexy, 53; Croup,
31; Remittent Fever, 28; drinking cold water, 20; Malformation, 31; Organic
disease of Heart, 18; Bleeding from Lungs, 13; Dropsy of Chest, 13; Scrofula,
12; while of casualties, 12 more occurred, and 8 more were killed or murdered.

“ The increase of Apoplexy, Unknown and drinking cold wpter, occurred
chiefly during the extremely warm part of last summer.

“The number of Still Born and Premature is precisely the same as last year.
There is a curious circumstance connected with this casualty that deserves a
remark; that is, the great disproportion of white males to white females, and
which does not take place between the sexes of the blacks.

“The greater fatality of male life in the white race commences before birth,
and continues throughout the first year of existence. This year almost 51 out
of every 100 died before reaching 5 years of existence, of whom over 25 were
white males, and 22 females — the rest blacks. This inequality does not con-
tinue so great after passing the year; there being buttrifling variation, (although
the males exceed,) between 1 and 2 — 2 and 5—5 and 10, until between 10 and
20, females predominate; between 20 and 30 they are nearly the same; but,
between 30 and 50, even to 60, the males are almost double in number to females.
Between 60 and 70, they vary a trifle; between 70 and 80, the females outnumber
the males, but from 80 upwards they are equal.

“Throughout the whole series there is a total excess of male deaths, of nearly
10 per cent., and this cannot arise from exposure or casualty alone. There is
not a disease of childhood, except Whooping Cough and Measles, in which the
male deaths do not preponderate. The same thing occurs with few exceptions,
at the other periods of life, excluding the peculiar diseases of females, and old
age. Of casualties of all kinds, the males exceed females only 148.

“ According to the lastcensus, the female population was not 5 per cent, greater
than the male. This constant loss of male population (which, taking the whole
series embraced in my last year’s report, of 32 years past, has been still greater,
having been nearly 12 per cent.,) is in some way or another supplied, or, inevi-
tably, the male race would eventually become extinct. It is for the purpose of
ascertaining the facts, that a register of births is desirable.

“ It is singular, in regard to the deaths of the coloured population, that the
males and females differ so little; the coloured females exceed the males only
one.

“ Of those diseases so fatal under the year some of them are fatal within a few
days of birth. Of Convulsions 638 died — 501 of them under the year; but 159
of them were not 7 days old; between that and 21 days, 177 died; between that
and 2 months, 79; and 28 between that and 3 months, leaving but 118 to divide
between the remaining three fourths of the year. Of Malformation and Pre-
mature, 77 died under 20 days.

“ I have placed in the table, on a line with the sex and age, the nativity of the

425

Lederle on Fungus of the Knee,

persons; in order, if possible, to show the effect, if any, this may have upon
disease. By a careful examination of which it will be seen, that of Apoplexy
49 were natives; and 104 Europeans; of Palsy, Epilepsy and Insanity, one half
of the males were Europeans, and of Bleeding from the Lungs, they exceed the
natives. Of Consumption, 1225, there were natives 665, and Europeans 539 —
11 of adjoining countries, and 10 unknown. The deaths by this disease,
excluding casualties of all kinds, is 1 out of 5 of the whole; of which 1 out of
9,293 are white natives, 1 out of 4,566 blacks, and 1 out of 2,877 Europeans.
Of Inflammation of the Stomach 28 were native and 36 Europeans. Organic
diseases of the Heart, 27 natives and 28 Europeans. Of Child bed and Puer-
peral Fever, 16 natives to 21 Europeans. Of Intemperance and Delirium Tre-
mens, 40 natives to 55. Suicides, 23 natives to 19. 41 natives and 44 Europeans
died of casualties. Out of 22 deaths from drinking cold water, 19 were Europeans;
and of Old Age 57 natives, 54 Europeans, and 3 from the adjoining British
provinces.

“ I have divided Europe into different sections in the tables, because of the
greater number from some sections; they are all included in these calculations.

“ It would tend very materially to an insight into these matters, if the census
gave any clue to the proportion of native population of this city; but as it does
not, much must be left to conjecture.

“ I have made no estimate of the deaths proportioned to the population; because
it will necessarily be very unsatisfactory until an accurate register is kept, based
upon the deaths, and not upon the interments only, in this city.

“ The tables are as extensive and minute as can be made; unless the various
occupations of the individuals could be obtained — a thing impracticable under
the present law.

“The novel plan of arranging these tables, introduced for the first time last
year, has, it will be perceived, been carried into still greater minutiae.” G. E.

Article XIX. De Fungo Genu nec non de TubercuUs in hoc morbo inventis.
Dissertation quam pro Summis in Mcdicina et Chirurgia honoribus rite capessen-
dis conscripsit ac publics defendit Franc. Josephus Lederlb, Badensis. Anno,
MDCCCXXXVIII. 8vo. pp. 81. Petropoli, 1838.

An Inaugural Dissertation on Fungus of the Knee and on the TuberculeSn which
occur in that disease. By F. J. Lederle, of Baden.

The disease denominated by the author, after several of the older surgical
writers, fungus of the knee, is that now better known by the name of white
swelling. In relation to the history, the symptoms, the predisposing and exciting
causes and the treatment of this affection, he has availed himself of the observa-
tions recorded by the best writers, without adding to them, however, any thing
of importance.

In regard to the pathology of the disease, so far at least as regards its imme-
diate cause, or the nature of the changes in the tissues of the knee joint, in which
it consists, but little satisfactory is known, and the author’s attempts to throw
light upon this important particular are very far from successful. He denomi-
nates the disease a dynamico-vegetative pseudoplasma of the synovial membrane
— a specific irritative-congestive affection of the nerves and vessels of the joint,
giving rise to the secretion into the fibrous tissues surrounding the knee, of a
peculiar viscid fluid, and occurring in persons where there already exists a latent
condition of the synovial membrane predisposing it to take on this specific irrita-
tion. A definition which leaves us as much in the dark as ever as to the pathology
of the disease, and leads to far less beneficial results in reference to its preven-
tion and cure, than would a minute and careful description of its phenomena — >
the various causes, predisposing and exciting, to which it may be referred, and
the lesions observed after death in the several tissues of the parts in which it
is seated.

36*

426 Bibliographical Notices,

The only interesting part of the dissertation before us, are the observations of
the author on the connection of the disease, of which he treats, with that peculiar
morbid condition of the organism, in which tubercles are readily produced in
nearly all the tissues by the slightest causes. Even on this point, however, he
has presented nothing new, nor has he given a very full digest of the facts in
relation to it recorded by others. D. F. C.

Article XX. Treatise on the Diseases produced by Onanism, Masturbation,

Self-pollution, and other excesses. By L. Deslandes, M. D., &c. Translated

from the French, with many additions. 12mo. pp. 252. Boston, 1838.

Among the numerous works that have appeared on the subjects treated of in
the volume before us, we have as yet met with no one in which is presented a
series of well-observed and carefully collated facts, tending to show conclusively
the real morbid influence upon the different portions of the organism of unnatural
excitations of the sexual organs. We have, it is true, the histories, almost with-
out number, of eases of various forms of disease, occurring in individuals of both
sexes, who were addicted to onanism or other kindred excesses; but the facts
of these cases have either been badly observed or carelessly detailed, for they
afford us no aid in determining how far the relators were warranted in attributing
all the morbid phenomena by which they were attended to the vicious practices
alluded to.

It may be received, we are perfectly aware, as a pathological axiom, tfiat pre-
mature and excessive excitement of any of our organs will, sooner or later, pro-
duce disease in that organ as well as in others with which it is closely related.
But the point upon which we wish to be informed is, what are the lesions directly
attributable to premature and excessive excitation of the genital organs in the
two sexes'? A careful investigation of this point will, we are convinced, show
that in some instances, at least, the most important diseases that are so generally
attributed to onanism, &c., result from the same morbid condition of the organism
upon which the tendency itself to onanism and other venereal excesses depend.

This is not the proper place to adduce the reasons which have led us to this
conclusion, nor to enter into a more extended examination of the subject in any
of its bearings. A perusal of the work before us has convinced us, however,
that it is one but little understood, and that it is still deserving of a more close
investigation, to the intent of deducing in relation to it accurate views as well
hygienic as pathological.

The treatise of M. Deslandes is certainly one of the best that has appeared on
the diseases produced by onanism, &c. The numerous facts it contains, never-
theless, do not appear to us to be well arranged, nor the inferences deduced from
them to be in every instance strictly legitimate. Its chief merit consists in its
presenting a synopsis of nearly all the leading facts recorded by the different
writers, who have treated, either professedly or incidentally, of the effects of
premature unnatural excitement of the sexual organs. Much good sense and
many judicious directions will be found in the second part, which treats of the
rules, preventive and remedial, relative to venereal excesses.

We have not compared the translation before us with the original French;
' it appears, generally speaking, however, to be executed with sufficient accuracy.
The “ many additions,” noticed in the title page, are embodied in the work,
without any marks sufficiently to distinguish them from the text of the author —
a practice which cannot be too severely censured. D. F. C.

Works on Ophthalmic Diseases.

427

Article XXL — A Treatise on the Diseases of the Eye^ and its Appendages. By
Richard Middlemore, M. R. C. S., Surgeon to the Birmingham Eye Infirm-
ary. London, 1835: 2 vols. 8vo. pp. 800 and 844.

Traite de P OphthaJmie^ la Cataracte et V Amaurose, pour servir de supplement au
Traite des Maladies des Yeux de Weller. Par J. Sichel, M. D. et C. &c. &c.
Paris, 1837: pp. 750, 8vo. avec 4 planches colories.

Manuel Pratique d* Ophthalmologies au Traite des Maladies des Yeux. Par Victor
Stoeber, M. D. &c. Bruxelles, 1837: pp. 389, 12mo. planches 3.

The Principles and Practice of Ophthalmic Surgery. Comprising the Anatomy ^
Physiology s and Pathology of the Eye^ with the Treatment of its diseases. By
Benjamin Travers, Esq., F. R. S. &c., and Joseph Henry Green, Esq., F.
R. S. &c. &c. Edited by Alexander Cooper Lee. London, 1839: pp.
242, 12mo.

Cours d' Ophthalmologies au Traite complet des Maladies de P ceils Professe puhlique-
ment a PEcole pratique de Medecine de Paris. Par M. Rognetta, D. Med. et
C. &c. &c. Paris, 1839: pp. 468, 8vo.

Lectures on Diseases of the Eye. By John Morgan, F. L. S., Surgeon to Guy’s
Hospital, and Lecturer on Surgery, at that Institution. Illustrated by 18
coloured plates. London: 1839. pp. 221.

The numerous contributions which have been made within the last few years
to the literature of Ophthalmic Surgery, manifest an increased attention to that
department of our science which cannot fail to be attended by the happiest
results. Not only must it be productive of a more general and better acqiuaint-
ance with the diseases of one of our most important organs, but also contribute
to the advance of Pathology and Therapeutics in general; for the superficial
position of some of the tissues of the eye and the transparency of others affords
opportunities for observing morbid processes and the influence of remedies upon
them, which cannot be obtained for the study of the diseases of the same tissues
in other parts of the body.

The first work in our list, that of Mr. Middlemore is an exceedingly elaborate
one, and constitutes in itself, almost a complete library of Ophthalmology. If
less rich in the results of personal experience than the Treatise of Mr. Law-
rence, it is far more comprehensive, and must be considered as entitled to the
first rank among the standard works of authority and reference.

The Treatise of Dr. Sichel, a German for some years residing in Paris, is
limited to the consideration of inflammations of the different tissues of the eye, and
to cataract and amaurosis. These affections, are, however, treated of in great
detail, and in a very able manner. Its principal fault is the dispositiorr which the
author indulges for the split-hair divisions and pure abstractions, characteristic
of German science.

The manual of Dr. Stoeber is ample in its scope, embracing an account of the
pathology and treatment of all the affections of the Eye and its appendages, but
presented in a very compendious manner. To nearly every section there is
a select bibliography, furnishing a reference to the best treatises and papers on
the disease of which it treats. It is the best compend on the diseases of the
eye that we have met with.

The work edited by Mr. Lee covers a wider field than any of the others we
have noticed, professing to describe the Anatomy, Physiology and Pathology
of the Eye and its appendages with the Treatment of its diseases. As all this
is comprised in 242 duodecimo pages, it wdll be readily conceived that the
subjects are treated of in mere outline. The best part of the work is that
devoted to the Physiology of the Eye and its appendages. This is exceedingly
interesting and may be read with advantage. The concluding part, that on the
Pathology and Treatment of diseases of the Eye and its appendages, is value-
less; how indeed could it be otherwise when it is attempted to discuss so exten-
sive a subject within the limits of one hundred duodecimo pages.

The Treatise of Dr. Rognetta is characterised by extensive reading and

428 Biblio graphical Notices.

research. The author seems perfectly familiar with the writings of the Italian,
French, and English writers on Ophthalmic Surgery, and has given us a good
abstract of their opinions. These are presented in the most concise language,
and as the work is closely printed, and in small type, the author has com-
pressed within narrow limits much useful information. A precise knowledge
of the virtues of the remedies made use of in the treatment of diseases of the
eyes, being, the author justly observes, essential, and this subject having been
hitherto much neglected, he has prefixed to his work the result of his studies
relative to the therapeutic powers of the belladonna, strychnine and mercurial
preparations.

The lectures of Mr. Morgan, the author informs us in his preface, are published
at the request of his pupils, and not from any wish on his part to appear before
the profession and the public, as an author of what will, he fears, be considered
by them as a very imperfect work, on the subject of Ophthalmic Surgery gene-
rally. *'• Neither as a lecturer nor as an author,” he observes, “do I put myself
forward as a competitor for professional fame and distinction with those who
have preceded me as the public instructors of their students on the science here
treated of, and as advocates for the connection of Ophthalmic and general Sur-
gery, but having been repeatedly urged, not only in private but publicly, by so
many of my class to supply them by publishing my lectures, with that, which
they considered would be a short text book for their studies at Guy’s Hospital
Eye Infirmary, I now do so in compliance with their wishes, in the hope of
affording them a permanent and perfect reminiscence of those instructions, which
I have spent so many proud and grateful hours in offering them. I caniiot refuse
to take all the chances of good or evil which may await me, in thus acceding
to the wishes of my young friends, although laying myself open, as 1 doubt not
I am now doing, to the censure of many, who, perhaps from various causes may
have expected something better than my present production.

“ My object has been to describe, concisely and clearly, the more common and
the more important diseases to which the eye is subjected, with what experience
has taught me to be the best general treatment, and to illustrate, as much as
possible, the analogy between diseases of the eye and those of other parts of the
body.”

It would be manifestly unjust to try a work by a higher standard than that
which the author proposes for himself, and it may, therefore, be sufficient praise
to award to Mr. Morgan the merit of having accomplished what he has designed
— to put forth a work which may serve as a short text book for students. His
lectures have no claim to higher merit.

There is one object which Mr. Morgan has had too constantly in view — the
desire to illustrate, as much as possible, the analogy between diseases of the
eye and those of other parts of the body. This, though a very legitimate and
praiseworthy design, has, we conceive, exerted an injurious influence over a portion
of his therapeutics. From the facilities afforded for the study of the diseases
of the eye, and the influence of remedial agents upon them, to which we have
already alluded, the treatment of ocular inflammation is in many respects in
advance of the treatment of this affection in similar tissues in other parts of the
body, as laid down in the works on general surgery. But Mr. Morgan, instead
of making use of the lights thus obtained to illuminate the obscure points in the
treatment of inflammation of parts concealed from view, has plunged the former
in the mists which involve the latter; and, consequently does not employ many
remedies which the fullest experience has shown to be often the most effectual
and prompt for the cure of inflammations of the eye.

Medical Transactions.

429

Article XXII. Medical Lexicon. Jl New Dictionary of Medical Science^ contain-
ing a concise Account of the various Subjects and Terms; with a Vocabulary of
Synonymes in Different Languages^ and Formulae for various Officinal and
Empirical Preparations^ ^c. 2d edition, with numerous modifications and
additions. By Robley Dunglison, M. D., M. A., P. S., &c. Philadelphia:
Lea & Blanchard, 1839. pp. 821, 8vo.

The merits of this work are already well known to the profession, the first edition
having been published several years since. It may be sufficient therefore to state,
that the present edition is a greatly improved one. It contains “ many hundred
terms more than the first,” as the author informs us in his preface, and has
experienced numerous additions and modifications which add much to its utility.
We trust that the circulation of the work will be such as, in some measure, to
compensate the author for the ungrateful toil of compilation.

Article XXIII. Transactions of the Medical Society of the State of New York^
Vol. iv. Part 2. Albany: 1839. pp. 56, 8vo.

Journal of the Proceedings of the Medical Convention of Ohio^ at its Third Session,
begun and held in the City of Cleaveland, on the \Uh and \bth days of May,
1839. Cleaveland: 1839. pp. 48, 8vo.

Minutes of the Medical Society of Tennessee, at the Tenth Annual Meeting, held in
Nashville, May, 1839. Columbia: 1839. pp. 44, 8vo.

Proceedings of the President and, Fellows of the Connecticut Medical Society in Con-
vention, May, 1839, with a List of the Members of the Society. Hartford: 1839.
pp. 16, 8vo.

These four publications possess peculiar interest from the circum*stance of
their having been issued nearly simultaneously, from the almost extreme points
of the Union, and bearing evidence that every where the profession are labouring
with zeal for the advancement of medical science.

The present part of the Transactions of the Medical Society of New York, is
not less valuable than the preceding ones. It contains the Annual Address of
the President, Dr. Laurens Hull; two Addresses, by Dr. A. Church, before
the Tompkins County Medical Society — one on Spinal Disease — the other on
Quackery; an Address before the same Society on the Objects, Ends, and Duties
of Medical Societies, by Dr. Daniel D. Page; a Translation, by Dr. H. B. Web-
ster, of Professor Caspar’s Essay on Suicide; and Statistics of the Medical Col-
leges in the United States, by T. R. Beck, M. D. To these are appended an
abstract of the Proceedings of the Society at its Annual Session in February
last, and some matters mainly of local interest.

The only article we have space to notice particularly is that of Dr. Church on
Quackery. This evil seems to be the favourite topic for medical discourses,
and, considering the extent to which it pervades the country, this cannot excite
our surprise. Its causes, and the sufferings it inflicts, have been fully set forth,
and ingenuity has been exhausted almost in devising means for putting an end
to it. — But hitherto in vain. Quackery, we fear, finds in the weaknesses of the
human mind too favourable a soil for its growth ever to be effectually checked,
much less for it to be wholly rooted out of society. The following very sensible
suggestions, nevertheless, of Dr. Church, for lessening its evils, if adopted,
would at least benefit the community, and add greatly to the respectability of
our profession, even if they failed in accomplishing the object for which they
are proposed.

“ We have seen,” he observes, “ how futile is legislation against that class
of men denominated quacks. They have too strong a hold on the sympathies of a
large class of the community — most of them ignorant to be sure, but many of them
respectable, and even influential. It has only served to bring these sympathies^
into active exercise, and cause them to be looked upon as an oppressed and per-
secuted set of men; as men who are useful in their vocation; and instead of

430

Bibliographical Notices.

creating- a distrust of them, it has manifestly operated to increase the number and
devotedness of their adherents. It is, therefore, my belief that if such a class
was unknown in law, there would be fewer of them.

“ Instead then of petitioning our Legislature to pass laWs restraining these
men, let us petition them to pass such a law as would be calculated to lessen
materially the diseases that more commonly fall into their hands. And this, I
think, may be done by requiring a more thorough course of preparation on the
part of the physician, before he is allowed to practice on his own responsibility.

“ Instead then of the present meagre requisitions of the law, is it not advisable
to enlarge them in regard to preparatory study, and place them on a footing with
those of the profession of law! I can see no reason why the knowledge of a
medical practitioner should not be as extensive, his philosophical researches as
profound, and his attainments in every respect as great, as those of any other
professional man, I am sure, no one acquainted with the duties of our profes-
sion, will say that the difficulties or importance of arriving at just conclusions,
are less in ours than either of the other professions. It is ignorance, gross igno-
rance on the part of our legislators, that has thus placed our profession in the
back ground. I do not know but many would think my ideas bordering on the
extravagant in regard to the subject of preparatory education, but it appears to
me, that either a regular course of classical studies in any of our colleges, or at
least four years devoted to the various departments of literature and philosophy,
is not too much to require of a young man previous to the commencement of pro-
fessional study. In the course of this time, if he has exercised proper diligence,
and that rightly directed, he will have obtained a respectable acquaintance with
literature, and become tolerably well grounded in the elements of the various
departments of philosophy: his mind will have acquired such a degree of disci-
pline, that he can commence and pursue, to good advantage, the study of any
science; he can far outstrip another of equal natural abilities who has been
deprived of these advantages. If, after enjoying these advantages, he were to
spend three years in the study of medicine, and at the end of that time spend one
year as a house pupil in a hospital, or, what may perhaps be better, in practice
under the direction and responsibility of a judicious practitioner of experience,
his education would be as nearly complete as could be reasonably demanded;
and he might set out on his professional career with confidence in his ability to
meet most of the emergencies of the profession. He would be placed above the
necessity of resorting to those little shifts to conceal his ignorance, to which men
of inferior attainments are so constantly obliged to resort, and to do which, as
well as to wheedle themselves into the good graces of the nurses and old w-omen,
draws so strongly on their mental resources as to leave them no room for pro-
fessional improvement. This, gentlemen, is no fancy sketch. It is drawn from
life, and this state of things will exist until our laws are so framed as to show
young men that our profession was designed as well to benefit mankind as to
afford them the means of an honourable livelihood. Our profession has become
numerous far beyond the wants of the community, and this in itself has a tendency
to retard the advancement of medical science. Not but what there should be a
sufficient number to excite an honourable competition, but when a profession
becomes so numerous, as that a large proportion must be idle a considerable part
of the time, it follows that they do not have opportunity to be in the habit of
constant observation of diseases, which is necessary to acquire the tact of expe-
rience. By requiring a suitable preparation before commencing professional
study, and extending the time of professional study itself, or by requiring some
time spent in actual practice, before granting licenses and diplomas, a consider-
able proportion would be deterred from entering the profession, who now do so
because it is the shortest road, and least expensive, to any kind of employment
above that of a common labourer.”

The Journ-dl of the Medical Convention of Ohio contains some matter of great
value, especially the address of the President, Dr. S. P. Hildreth, “on the
climate and early history of the diseases in Ohio.” In this interesting paper
the author treats of 1st, the topography and primitive aspect of the country on

Medical Addresses,

431

the Ohio river; 2d, the climate and its changes from the effects of cultivation;
3d, the diseases of the aborigines.; 4th, the diseases of the first white settlers,
and early epidemics; 5th, the treatment of diseases thirty years since; 6th, recent
epidemics; 7th, diseases common to this climate, with the modifications which
have taken place from changes in diet, fashions, habits, &c.

The Minutes of the Medical Society of Tennessee, in addition to an account
of their annual meeting, contain an address by Dr. A. H. Buchanan, of Colum-
bia, on quackery; also, a very interesting case by the same, illustrative of the
etiology of spontaneous amputation of the limbs of the foetus in utero; and some
extracts from an address by F. Stith, M. D.

The address of Dr. Buchanan is well written, and contains some useful infor-
mation. The measures he wishes to be adopted, for the protection of the people
from imposition, are “ rigid legislative enactments.” The case will be found in
another department of this Number. As to Dr. Stith’s paper, we could not do
justice to it without giving it entire, as we must confess that his aim anff
meaning are not discoverable by our limited intellect — a category in which we
shrewdly suspect the author himself to be included.

The proceedings of the Connecticut Medical Society are of merely local in-
terest.

Article XXIV. On the Methods of Acquiring Knowledge, An introductory
Lecture to the Course of the Institutes of Medicine^ for the Session 1R38-39. Deli-
vered in the University (f Pennsylvania, Nov, 6. 1838. By Samuel Jackson.
Philadelphia: 1838. pp. 32, 8vo.

Valedictory Address to the Students in Medicine of the College of Physicians and
Surgeons of the University of New Yorh. Delivered Feb, 28, 1839. By John
B. Beck, M. D., Prof. Mat. Med. and Med. Juris. New York: 1839. pp.
24, 8vo.

An Address delivered to the Students of the Louisville Medical Institute, in the pres-
ence of the citizens of the place, at the commencement of the Second Session of the
Institute, Nov. 13. 1838. By Joshua B. Flint. M. D., Professor of Surgery.
Louisville, Ken.: 1838. pp. 31, 8vo.

An Annual Address to the Candidates for Degrees and Licences in the Medical Insti-
tution of Yale College, Feb. 26. 1839. By Thomas Miner, M. D., Member of
the Board of Examination, and late President of the Connecticut Medical
Society. Published at the request of the Class. New Haven: 1839. pp.
20, 8vo.

An Address delivered to the Graduates of the Philadelphia College of Pharmacy,
April 23, 1839. By Joseph Carson, M. D. Prof. Mat. Med. and Pharm.
Philadelphia: 1839. pp. 16, 8vo.

These addresses are all appropriate to the occasions on which they were deli-
vered, and creditable to their authors.

The lecture of Professor Jackson is of a high order of merit. It bears the
impress of the author’s richly stored and philosophical mind, and exhibits a depth
of reflection and a freshness and originality in the views rarely met with in pro-
ductions of its class.

The different methods, with their respective advantages and defects, by which
knowledge is acquired and rendered accurate; by which sound and judicious
opinions are formed; by which truth is to be sifted and separated from error; are
clearly set forth, and justly estimated.

Professor Beck’s valedictory is an exceedingly well written and judicious
address, and contains sound advice relative to the means by which professional
eminence may be promoted.

Professor Flint discusses the objects of the medical profession; the personal
qualities and accomplishments calculated to secure eminence therein, and some
of the sources and aids of medical improvement during the period of pupilage
and afterwards, in a manner which denotes a facility at sketching, a sprightly
imagination, and considerable talent for sarcasm. His pictures of French

432

Bibliographical Notices.

medicine, and particularly of French surgery, are clever fancy sketches; but that
it was judicious to exhibit them to a miscellaneous audience and to young stu-
dents, who are not always competent to distinguish badinage from sober earnest,
and might mistake these caricatures for portraits, is to say the least doubtful.

The principal duties that devolve on those who desire to rise to eminence in
the profession are inculcated by Dr. Miner, in a plain and sensible manner.
With much to praise, there is, however, one passage to which we regret to say
exception may be taken. Whatever may be thought of the accuracy of the fol-
lowing laudatory notice, it can hardly be considered to be in the best taste.

“Nothing is more common than to overlook and undervalue the high advan-
tages which we enjoy. In this point of view, I have often thought that this
medical institution has not been sufficiently appreciated, either by the medical
profession or the public. 1 feel confident in boldly asserting, that the means for
obtaining a thorough medical education, in probably all its branches, are fully
equal to those of any other school in the country. The opportunities for acquiring
a minute knowledge of anatomy are as good, and the means are furnished at as
moderate an expense, as at any other place. Our course of chemistry is allowed
to be unrivalled. Our courses upon surgery, and upon theory and practice, will
respectably compare with any others. Upon one important branch we are de-
cidedly superior to all our cotemporaries. In the study of indigenous materia
medica, which was so happily begun by the first professor, who may be consi-
dered as the founder of this branch of materia medica, and which has been con-
- tinned by his successor, we are decidedly without a rival, and are probably half
a century in advance of the age. It is probable that more indigenous articles
are regularly employed by those who have been educated in this school, or have
been connected with it, and their nature is better understood, than by all the
other physicians of the United States, or of the world. In this respect, justice
has never been half done to this institution, either at home or abroad.”

Professor Carson’s address is an exceedingly neat one, and the topics dis-
cussed are judiciously selected. Correct views are presented of the science of
pharmacy, the objects which the pharmaceutist should strive to attain, the
means he should employ, and the motives by which he should be governed.

Article XXV. Outlines on Physiology; with an Appendix on Phrenology. By

P. M. Roget, M. D. &c. First American edition, revised, with numerous

notes. Philadelphia: 1839. pp. 516, 8vo.

The present volume is made up of the two articles “ Physiology” and “ Phre-
nology,” contained in the last edition of the Encyclopaedia Britannica.

The outlines present a very interesting, and, in most particulars, accurate
sketch of the present condition of physiology; which may be placed, with great
propriety, in the hands of the student, as an introduction to the more extensive
and elaborate treatises, with the contents of which he will be required subse-
quently to make himself acquainted.

Individuals not of the medical profession, who may desire to acquire a general
knowledge of physiology, will also find the outlines of Dr. Roget to be very
well adapted for their use.

The notes appended to the present edition are judicious and useful; supplying
several omissions of the author, correcting some of the particulars which, in the
opinion of the American editor, were either erroneous or doubtful, and furnish-
ing references to works Irom which more ample information may be obtained.

Of the “ Appendix on Phrenology” we have little to say— that it is not con-
sidered by phrenologists either a fair or conclusive refutation of their peculiar
views ought to be borne in mind by the reader. As we are convinced that truth
will ultimately be the gainer, by every species of attack she may sustain — inas-
much as men’s minds are often in this manner instigated to her investigation—
the Appendix to these outlines, however much we may differ from some of
the views there set forth, does not deter us from recommending warmly the
work to the perusal of all interested in the study of physiology. D. F. C.

433

SUMMARY

OF THE

IMPROVEMENTS AND DISCOVERIES IN THE
MEDICAL SCIENCES.

GENERAL ANATOMY AND PHYSIOLOGY.

1. Case of Anaesthesia (Loss of Sensation') in the course of distribution of the Fifth
Nerve^ with Remarks. By Dr. Romberg of Berlin. — It is well known how few
have been the instances of pathological conditions of the fifth nerve which have
been recorded, compared with the numberless cases of affections of the N. faci-
alis, since Sir C. Bell’s work has given to this branch of pathology so much
interest. It must be admitted, however, that diseases of the fifth pair furnish
more satisfactory evidence of the real nature of their function than can be ob-
tained by means of vivisections. The following is a case of interest, both with
regard to the physiological character of this nerve and the diagnosis of its ab-
normal conditions:

A widow, aged forty-two, fell down stairs backwards, and received a violent
blow on the occiput. A twelvemonth afterwards her catamenia ceased. From
this time she was subject to attacks of sneezing, which increased so much, both
in violence and duration, that the slightest circumstance provoked the convul-
sions, and her sleep was continually disturbed by them. The examination of
the nostrils afforded no clue to the cause of this condition, and I, therefore,
sought to account for it in the injury done to the head, implicating, possibly, the
nasal filaments of the fifth nerve. On investigating the regions to which the first
and second branches of the fifth are distributed, I found the sensibility undimin-
ished, but upon arriving at the region of the third branch, I found complete
anaesthesia in its whole extent. I will here detail the symptoms, as I have
repeatedly demonstrated them to my pupils, and likewise in the presence of
Prof Miiller and other friends. I always took the precaution of effectually
binding the patient’s eyes, which I deem to be necessary in such investigations,
in order to guard as much against simulation as to prevent the patient being
misled by the sight of the instrument used.

The left half of the under lip, both on its external and internal surface, and
the left half of the chin, did not betray the least sensibility bn being pricked
with a sharp vaccinating needle; this was likewise the case with the left ear
and the meatus externus. The same parts were insensible to the flame of a
taper. The insensibility extended upwards to the left temple, bordering on the
hairy scalp, and including the tongue also. There was no pain caused by
pricking, nor was there perception of heat or cold on the side, point, or surface
of the tongue on this side.

On the right side of the head all these parts were in full possession of their
sensibility, and indeed all the other sensitive nerves of the left side preserved
their integrity, so that the limits of the distribution of the third branch of the
fifth could be accurately marked out by means of pricking the skin. If the
needle came in contact with the skin of the temples towards the forehead, the
No. XLVHI. — August, 18B9, 37

434

Progress of the Medical Sciences,

patient gave immediate signs of pain, from the presence of branches of the
frontalis: the same result ensued on injuring the integuments coverLr^ the hori-
zontal portion of the lower jaw, from the presence of the subcutaneous branches
of the third cervical nerve.

Besides the loss of sensation, with reference both to heat and cold and me-
chanical injury, which the tongue displayed, I found that the sense of taste was
obliterated. No kind of substance, fluid or solid, bitter or otherwise, produced
the least impression on the left side, whilst on the right, they were discrimi-
nated with precision. I tried this experiment with various substances, as colo-
cynth, various salts, acids, &c.

Notwithstanding this partial disturbance of the sensibility of the left side of
the face, nothing of the sort existed in the motory function. Neither the ex-
pressive or mimical {rnimische), nor the respiratory or masticatory motions were
impaired. The same was the case with the masticatory and articulatory mo-
tions of the tongue. The nutrition of the left side was unimpaired; the dimen-
sions, colour, and moisture of both sides being alike, and blood flowing with
the same readiness, and ceasing equally soon on the left side as on the right.

From these premises I drew the following diagnosis: “ The anaesthesia which
extends throughout the distribution of the third branch of the portio major of the
fifth, indicates an isolated affection of this nerve, and, indeed, a compression of
its trunk, since the loss of sensibility has been unaccompanied throughout with
painful sensation in the parts to which the nerve is distributed. The cause of
the existing pressure must Include the whole of the primitive filaments belong-
ing to this subdmsion of the nerve, and, consequently (in all probability), the
trunk of the nerve itself, for there is an entire absence of sensibility in all the
ergans supplied by it; and, on the other hand, the immunity of the parts sup-
plied by the remaining two branches of the fifth, prove that the pressure cannot
he situated in the Gasserian ganglion, else there would be more or less implica-
tion of other parts in the anaesthesia; neither can the seat of pressure be external
to the foramen ovale of the sphenoid bone; for from this point the motor and sen-
sitive fibres of the third branch are in such close juxtaposition, that it would be
impossible that one class of functions should be so completely annihilated and
the other be left unimpaired, (it will be remembered that the masticatory mo-
tion of the left side was not weakened.) 1 am, therefore, led to assume the pre-
sence of a tumour, either of the dura mater or of the bone, so situated as to
•Cause pressure on the third branch of the fifth nerve, previous to its passage out
^of the foramen ovale.’’

On the 19th March, the patient died of dropsy, and the body was brought for
examination to the Anatomical Theatre, in Berlin, Previous to the section, I
Tcpeated my diagnosis to those present, viz.. Prof. Muller and Drs. Henle,
Schwann, and Philipp.

. The investigation of the contents of the cranium, gave the following result:
The surface of the brain was covered with a gelatinous, and more or less white,
-opaque exudation, A portion ©f the brain, of about the size of a walnut, situated
<m the inferior surface of the posterior lobe of the left hemisphere, and cor-
responding to the posterior horn of the lateral ventricle, was softened, but with-
out any sign of vascular injection in the neighbourhood. In other respects both
the brain and spinal cord were normal. The third branch of the fifth nerve, just
at its point of entering the foramen ovale, was surrounded by a reddish vascular
tissue, consisting partly of fibres and vesicles. Closer investigation showed it
to be an exudation into or hypertrophy (Wucberung) of the neurilema, passing
into the dura mater, in the direction of the origin of the nerve, and becoming
gradually lost upon the neurilema, inclosing the nerve after its passage through
the foramen ^dvaie. The neurilema was thickened, and reddish throughout that
portion which lies in the sphenoid bone, but becoming less so as it approached
the spot where tjhe ganglium oticum lies in contact with it. As far as the neu-v
rilema was altered in appearance, the nerve appeared to be thicker and firmer,
and to possess a flight yellow color. The third branch of the Gasserian gan-
glion was the only portion of the nerve that had suffered any alteration. The

435

Anatomy and Physiology,

motor branch lay to the inside of the nerve, and joined it below the spot de-
scribed. All the nerves supplying the buccinator, pterygoid, and temporal mus-
cles were normal, as likewise those of the tongue and lower jaw, the quintus of
the right side, and the glosso-pharyngeal nerve of both sides.

Remarks. — These observations could not have been made at a more oppor-
tune season than the present, when the controversy concerning the gustatory
nerve engages so much the attention of physiologists. I think I shall not be
presuming too much, if I consider this case as conclusive evidence of the truth
of the theory which maintains that real gustatory fibres are at least contained
within this branch.

I express myself thus in order to avoid the general but erroneous view, that
this nerve is an aggregate of homogeneous filaments; for this case incontestibly
proves that sensitive and gustatory elements are included in it. Pathological
facts are in this case of infinitely more value than experiments on animals; and
this is true of all the perceptions of sense. In the experiments respecting the
participation of the glosso-pharyngeus and lingual is in the sense of taste, neglect
of this consideration led to erroneous conclusions. The sensitive functions
of the tongue were limited to those of mere sensation and taste; and a third, one
of considerable importance, was overlooked, although it is one that the most
simple experiment may serve to establish. For instance, if the finger be passed
over the point, edge, or middle of the tongue, nothing but ordinary sensation is
excited; but as soon as we approach the papillae vallatae and the root of the
tongue, the feeling of nausea is excited together with a sense of choking, a de-
cided reflex action. It is in these papillae, and also in the velum and other parts
which when irritated give rise to the same sensations, that the filaments of the
nervus glosso-pharyngeus* are distributed. In most of the experiments made
upon animals with reference to this circumstance,! it is stated that nausea and
strangulation were excited in cases where the glosso-pharyngeus was unin-
jured; but I think it was incorrect to ascribe their production to the influence of
taste. I consider that the greater abundance of the papillae vallatae has refer-
ence, in animals, to the instinct possessed by them, inasmuch as 1 consider the
sensation of nausea, &c., to be of more importance in enabling them to discri-
minate between noxious and innocuous food than mere taste. The observations
of Rudolph Wagner! seem to strengthen this opinion, for he shows that papil-
lae vallatae appear to have constant reference to the alimentary instinct of the
different mammalia in their form, number, size, and situation. I need not
observe that I differ from him in attributing the function of taste to the glosso-
pharyngeus.

From the reasons above stated, I do not hesitate in terming the glosso-pha-
ryngeus the nerve of alimentary instinct. This, too, explains its uniform presence
in all classes of animals, whilst the lingualis is wanting in birds.

Besides the specific sensitive function of the glosso-pharyngeus, its peculiar
reflex action, above alluded to, is very deserving of attention. It is exceedingly
interesting to observe how different are the reflex functions peculiar to contigu-
ous organs, even when produced hy the same stimulus. The irritation of the
vagus in the glottis produces cough; in the fauces, the same nerve being irri-
tated, excites the act of swallowing; the glosso-pharyngeus causes the pheno-
mena we have described. A very instructive instance of this variety of reflex
action is given by Marshall Hall, (Lectures, &c., p. 23,) where a person intro-
duced a feather into the mouth in ordOr to cause vomiting, by irritating the
fauces, but passing it too far it became subject to the peculiar action of the

* The author terms the nerves frequently thus, “via glosso-pharyngea”

instead of nervus glosso-pharyngeus. His object is to avoid the apparent confounding
several distinct kinds of filaments together, under a term which implies uniformity. —
Tuans.

t See Panizza and Valentin; Report, fiir Anatomic u. Physiol. 1837. 2 Bd. 2 Abthh
S.220.

f Neu Notizenaus dem Gebiete dcr Natur u. Heilk. No. 75.

436

Progress of the Medical Sciences,

cBSophagus, and was drawn into the stomach. These reflex actions may be
made use of as reagents in the investigation of the offices of sensible nerves; and
as 1 lately found, whilst experimenting upon a horse, that irritation of the ner-
vus vagus in the neck caused cough, so the irritation of the glosso-pharyngeus
would, I doubt not, in all cases produce the sensation of choking.

The next important commentary that this case affords is the elucidation of
the law of isolated conduction (isolirte Leitung) and co-sensation. The first of
these laws insured the accuracy of the diagnosis, whilst the latter offers an ex-
planation of the convulsive sneezing. For we can best comprehend the con-
nection of the cause and effect, by supposing that this peculiar convulsive
sneezing was produced through the radiation of the sensation, and transference
of the irritation of the filaments of the third branch, to the nasal filaments of the
first, (whether in the ganglion Gasseri or within the central organ I will not
decide,) and by means of the reflex respiratory motion. The co-sensation in
the cerebral end of the nasal twigs was so acute and the tension so considera-
ble, that any the least stimulus gave rise to the sternutatory action, so that my
experiments on the sensation of the face was often interrupted thereby.

We have hitherto only considered the case in its physiological characters,
but it teems likewise in points of pathological interest; particularly of course
with reference to the fifth pair of nerves, concerning which we know as yet so
little.

In the hyperaesthesia of this nerve (tic douloureux,) the confusion and unin-
lelligibility of the writings on the subject afford sufficiently convincing proof
how little is known respecting it, and the paralysis of the fifth was a complete
terra incognita, first discovered by the genius of Bell. Since that time some
few cases have been published, wffiich serve to throw a brighter light upon the
subject. The paralysis afifects either the sensible or motor branches, or both at
once. Simple means suffice to establish this. Further, it must have either a
peripheral or central origin; and here I would observe, that the former has a
more extended sphere than is usually ascribed to it. It has been a common
error in pathology to view^ the aggregate of nervous fibres, as they leave the
basis of the brain as the nervous root or origin of the nerve, and, consequently,
to include their diseases, whilst in this part of their course, under the head of
affections of the central organs. But a nerve must be considered as peripheral
in every portion of it, from its earliest origin to its remote termination. Thus,
the paralysis of the fifth is peripheral, whether its inducing cause be seated in
the surface of the face, in the sphenoid bone, the ganglion Gasseri, or in the
neighbourhood of the pons varolii. The real locality of the affected portion
may be determined diagnostically. The more isolated the anaesthesia, the more
peripheral is the cause.

Thus, when caused by the extraction of a molar tooth, the anaesthesia was
confined to half of the lower lip, as in other cases it is limited to the alae nasi or
the surface of the eye, &c. We may thus pursue diseases of the nerve in its
course, until the loss of sensibility of the entire surface of the face supplied by
it, combined with paralysis of the masticatory muscles, indicates an affection
either of the ganglion Gasseri or the parts in its immediate neighbourhood. In
cases where the ganglion is affected, another class of symptoms makes its
appearance, possessing considerable physiological interest, viz , disturbance of
the vegetative functions in the parts which are at the same time deprived of
their sensation; this produces in the eye inflammation, suppuration, and ulcera-
tion, in the nasal and oral cavities redness, and haemorrhage, and wasting of the
gums. Such instances have been observed by Serres and Abercrombie.* — B.
and F, Med. Rev., April, 1839, from Miiller's Archiv. 3 Heft. 1838.

2. Malformation of the Placenta. — Dr. Burner of Thaurin, has recorded in a
recent Number of Medicinisches C rrespondenz-Blatt, a case in which he found the
placenta completely divided into two equal parts, and held together solely by

* Diseases of the Brain, p. 424. Last Edition.

437

Anatomy and Physiology.

the chorion and amnion. The umbilical cord bifurcated three inches above its
insertion into the placenta, each branch consisting of two arteries and a vein.
The two placentae with the cord, weighed four pounds two ounces. The infant
was .a first child still-born, at full time, well formed, but its extremities were
smaller than usual.

This case is very remarkable for the great weight of the placenta, and its divi-
sion into two equal parts. Meckel {Handbuch der Pathol. Jinat. Leipzic, 18T2,
vol. i. p. 86) reports several examples in which the placenta was divided into
two parts, but in all, one part was larger than the other in the proportion of 1 to
12, or 1 to 10, or of 1 to 8. Rohault {Observ. Jinat. Turin, 1724, p. 7) saw
placentae divided into three, and in one case into four parts, but all of different
sizes. Hoboken {Anat. Secund. Human. Repet. Ultraj^ 1765, p. 198,) speaks of
placentae divided into four unequal parts. Meckel {loc. cit.) saw a placenta
divided into five parts, four of which were nearly equal, and the fifth double the
size. Kerkringius {Observ. Anat. p. 37,) and Wrisberg (iV. Comment. Soc. Got.
vol. iv. p. 73) saw a placenta divided into seven parts.

3. Transfusion of Blood. — Professor Bischoff of Heidelberg formerly published

his confirmation of the experience of Prevost, Dumas, and Dieffenbach, to the
effect that fresh and unagitated blood procured from any of the mammalia, caused
instantaneous death upon being injected into the veins of a bird. Upon repeating
this experiment before his class, in the course of this and the previous summer,
he was much astonished at not finding the usual fatal result to occur. In vain
did he attempt to explain the cause of the disappointment, until it occurred to
him whether, perhaps, there may be a difference in the effect of venous and
arterial blood. In his former and latter experiments, he had taken a cat, rabbit,
or young dog, and obtained blood from it by cutting its throat. It was therefore
possible, that at different times the syringe had taken up different kinds of blood.
To decide this, the following experiments were performed: In one leg of a dog
the vena cruralis was exposed, and the arteria cruralis in the other. First, some
blood was taken from the vein, and about a drachm was iiijeeted into the left
jugular vein of a healthy cock. The bird died in a few seconds, under the most
violent convulsions: A portion of blood from the artery of the other leg was

then injected into the corresponding vein of a hen. The bird was powerfully
affected by it, but the experiment did not prove fatal; in a short time it had
recovered itself, and a small quantity of venous blood was injected, upon which

"the fowl died immediately. Precisely similar experiments Were tried some
time afterwards, and with the same results; here a few drops only of the venoue
blood proved fatal. A strong goose, also, bore the injection of arterial blood,
but venous blood caused the most violent convulsions and death. What could
be the cause of this remarkable difference! In order to avoid the possibility of
other causes operating, every precaution was adopted. Thus, in order to prevent
the possibility of plethora, a small quantity of blood was allowed to escape first;
due care was also taken to avoid the injection of air into the veins, which how-
ever is by no means always attended with fatal consequences. There is then
no doubt left, in the opinion of Dr. B., that it is the venous blood which exer-
cises the fatal influence; how it acts, is a question which remains to be solved;
and its solution will no doubt prove of service in increasing our knowledge of
the differences between venous and. arterial blood. — B. and F. Med. April,
1839, from Miiller’s Archiv. 4 Heft. 1838.

4. On the Decussation of Fibres at the junction of the Medulla Spinalis with the
Medulla Oblongata. By John Hilton, Esq. — The author first alludes to what
usually happens in affections of the brain, namely, that the loss of voluntary
power and of sensation manifest themselves in the opposite side of the body to
that in which the cerebral lesion exists, a fact which has been attempted to be
explained by the crossing of the fibres at the junction of the medulla oblongata
with the anterior or motor columns of the medulla spinalis; but such a structure,
he observes, affords no explanation of the loss of sensation. The author then,

37*

438

Progress of the Medical Sciences,

referring to the communication of Sir Charlos Bell to the Royal Society, in the
year 1835, describing a decussation connected with the posterior columns, or
columns of sensation, mentions that the accuracy of these dissections was
doubted by Mr. Mayo and other eminent anatomists. The author proceeds to
state that the symptoms of cerebral lesion do not always take place on the oppo-
site side of the body to that in which the lesion of the brain exists, but that they
occur sometimes on the same side; that the loss of power and of sensation,
although confined to the same side, may exist in either the upper or the lower
extremity; but that both are not necesarily implicated; and that, in fact, cases
occur where there are marked deviations from what may be considered the
more common occurrence. Having observed such cases, and not being aware
of any satisfactory explanation, the author examined with care the continuation
upwards of the anterior and posterior columns of the spinal marrow into the
medulla oblongata and found that the decussation at the upper part of the spinal
marrow belonged in part to the columns for motion, and in part to the columns
for sensation; and further, that the decuSsation is only partial with respect to
either of these columns; thus elucidating by the observation of the actual struc-
ture what before appeared very unsatisfactory in pathology, and anomalous in
disease.

The paper is illustrated by drawings made from the dissections of the author.
Proceedings of the Royal Society, 1837-8. No. 34.

5. An account of some Experiments on the Blood,, in connection with the theory
of Respiration, By John Davy, M. D. &c. — The author has investigated,
experimentally, several of the important questions connected with the theory of
respiration and of animal heat; and arrives at the following results. He finds
that the blood is capable of absorbing oxygen both from atmospheric air, and
from oxygen gas, independently of putrefaction. After blood has been agitated in
common air, a trace of carbonic acid, not exceeding one per cent., is found in
the residual air; but when pure oxygen is employed, no carbonic acid can be
detected in it by the most carefully conducted trials. When pure carbonic acid
is brought into contact with blood, or serum, over mercury, and moderately agi-
tated, the absorption of gas exceeds the volume of the fluid. Both arterial and
venous blood are rendered very dark, and serum more liquid by the absorption
of this gas to saturation. JSerum, in its healthy state, is incapable of absorbing
oxygen, or of imrnediatelj furnishing carbon to form carbonic acid: and after it
has absorbed carbonic acid, only one-tenth of the absorbed gas is expelled by
successive agitation with atmospheric air, or with hydrogen. The author is
inclined to think that the alkali in the blood, in its healthiest condition, is in the
state of a sesquicarbonate. In the majority of trials manifest indications of the
disengagement of air from blood in vacuo were obtained: but as it occasionally
happened that no air could be thus extricated, the author is induced to believe
that the quantity of air contained in the blood is variable; and he has found this
air to consist solely of carbonic acid gas. It would also appear, from the expe-
riments detailed in this paper, that a portion of oxygen exists in the blood, not
capable of being extracted by the air-pump, yet capable of entering into com-
bination with nitrous gas; and existing in largest proportion in arterial blood.
The absorption of oxygen by blood is attended with an increase of temperature.

The experiments of the author tend to show that the lungs are absorbing and
secreting, and perhaps also inhaling organs, and that their peculiar function is
to introduce oxygen into the blood, and separate carbonic acid from the blood;
and they favour the idea that animal heat is owing, first, to the fixation or con-
densation of oxygen in the blood in the lungs during its conversion from venous
to arterial; and secondly, to the combinations into which it enters in the circu-
lation in connection v.'ith the different secretions and changes essential to animal
me.^Ibid.

6. Diurnal variations of the Pulse. — In Guy's Hospital Reports for April last,
there is an account of some interesting researches on this subject by Professor

430

Anatomy and Physiology.

Guy of King’s College, London. The results as given by the author of experi-
ments made upon himself are, as follows—

1. The pulse of a healthy adult male in a state of rest, unexcited either by
food or exercise, is most frequent in the morning, and gradually diminishes as
the day advances.

2. The pulse diminishes in frequency more rapidly in the evening than in the
morning.

3. The diminution of the frequency of the pulse is more regular and progres-
sive in the evening than in the morning.

4. The effect of food is greater and more lasting in the morning than in the
evening; and, in some instances, the same food which in the morning produces
an effect considerable both in amount and in duration, has no effect whatever in
the evening.

7. Products of Respiration at Different Periods of the Day. — In the Philosophical
Magazine for June last there is an account of some interesting experiments on
this subject by Charles T. Coathupe, Esq.

“The periods selected for the experiments were.

From 8 a.m. to 9^ a.m. before breakfast.

9^ a.m. to 12 noon 1 during the digestion of breakfast and before
12 noon to 1 p.m. 5 “luncheon.”

1 p.m. to p.m. before dinner.

5t p.m. to 84^ p.m. during the digestion of dinner.

8| p.m. to 12 night.

Habits of the operator.

At 9| a m. a slender breakfast.

1 p.m. to 2 p.m. “luncheon.”

5t p.m. a good dinner, with a pint of wine.

8| p.m. one small cup of tea.

10 p.m. occasionally one glass of weak brandy and water.

12 to 1, bed time.

Age, 38 years. Stature, 5 feet 8 inches. Weight, about 140 pounds.
Average pulse, 60 to 62 per minute. Average respiration, 18 to 21 per minute.

The following are the results:

1st period 8 a.m. to 9^ a.m. 32 experiments indicated 4.37’^ w

2d “ 10 a.m. to 12 noon 15

3d “ 12 noon to 1 p.m. 7

4th “ 2 p.m. to 5ip.m. 29

5th “ 7 p.m. to 8| p.m. 17

6th “ 9 p.m. to midnight 24

“ “ 3.90 I ° bD

“ “ 3.92

“ “ 4.17 f g §

“ “ 3.63 I

“ “ 4.12 J

124 experiments, comprising 8 days.

“ Hence we find the carbonic acid gas produced by respiration to be a variable
quantity, that it is less during the period of active digestion, that it increases
with increased abstinence from food, and it varies in the same individual at
similar periods of different days. It also appeared during these experiments,
that excitement of any kind (whether from the exhilarating stimulus of wine, or
from the irritating annoyances which are wont to occur to most folks who are
actively engaged,) caused a diminution of carbonic acid in the air respired, as
compared with the ordinary average of that respired at a similar period of the
day, and during a state of ordinary tranquillity. The total daily average indicated
4.09 per cent, of carbonic acid gas. The maximum observed at any single
examination was 7.98 per cent. It was at 8 a.m. February 5th. The minimum
observed at any single examination v/as 1.91 per cent. It was at 7^ p.m. Feb-
ruary 7th.”

These results differ widely from those of Messrs. Allen and Pepys, (Philos.
Trans. 1809;) which Mr. C, ascribes, in part, to the experiments of Messrs. A.
& P. being made either before breakfast or immediately before dinner, the periods

440

Progress of the Medical Sciences,

of the day in which Mr. C. has shown the respiration to contain its maximum
quantity of carbonic acid gas, and, in part, to the increase in the carbonic acid
gas eliminated by protracting in their experiments the respiratory process.

Mr. C. thinks, from his own observations, and from the experiments of others,
that the following details, connected with this subject, may be faithfully relied
on: —

“ 1. The average number of respirations made by most adult healthy indi-
viduals (varying from 17 to 23 per minute) may be stated as 20 per minute.

“2. The average bulk of air respired at each respiration made by such indi-
viduals (varying from 14 to 18 cubic inches) may be stated as 16 cubic inches.

“ 3. The average daily amount of carbonic acid gas found in the air respired
by such individuals (varying at its extremes from 1.9 to 7.98 per cent.) may be*
stated as 4 per cent.

“ Hence 460,800 cubic inches, or 266.66 cubic feet of air pass through the
lungs of a healthy adult of ordinary stature in 24 hours, of which 10.666 cubic
fbet will be converted into carbonic acid gas, = 2386.27 grs. or 6.45 ounces
avoirdupois, of carbon. This gives 99.6 grs. of carbon per hour, produced by
the respiration of one human adult, or 124.328 pounds annually; and if we mul-
tiply this by 26^ millions (being the calculated population of Great Britain and
Ireland for the year 1839) we have 147,070 tons of carbon as the annual product
of the respiration of human beings at present existing within the circumscribed
boundaries of Great Britain and Ireland.

“ Hence also the maximum quantity of fresh atmospheric air that can possibly
be required by a healthy adult during 24 hours, even supposing that no portion
of the air respired could be again inspired, will not exceed 266.666 cubic feetP

PATHOLOGICAL ANATOMY AND GENERAL PATHOLOGY.

8. Perforation of the Stomach from Morbid Causes. — This may be the result:-—
1st. Of simple ulceration; sometimes of an acute, but more commonly of a
chronic character. 2. Of scirrhous ulceration. 3. Of a solution of the parietes,
which is supposed to take place after death. Mr. Alfred S. Taylor has col-
lected several cases illustrative of this remarkable disease, and thinks that they
warrant the following conclusions:

“ 1. Perforation of the stomach seems to attack frequently young females from
18 to 23 years of age, generally unmarried. According to Andral, females who
have been recently delivered, and those persons who have undergone severe
operations, are likewise subject to it. The disease is not exclusively confined
to females, or to a particular age. In the preceding observations, two cases of
males, at 60, have been referred to.

“ 2. The preceding illness is commonly slight, rarely amounting to more than
simple dyspepsia or slight irritation of the stomach after eating, with want of
appetite. These symptoms may have existed for some weeks or months before;
but have been altogether disregarded, and perhaps not even noticed by those,
with whom the deceased associated. In other cases, the gastric disturbance
is more severe: but as a medico-legal fact, it is important to remember, that
these cases, with severe precursory symptoms, appear to constitute the smaller
number. Dr. Abercrombie remarks, that ‘ this affection may run its course,
almost to the latest period, without vomiting; and with scarcely any symptom,
except the uneasiness w^hich is produced by eating, and which subsides entirely
a few hours after a meal.’ Some have considered that a chlorotic state of the
system might dispose young females to this affection; but there does not appear
to be any sufficient ground for this opinion. It has happened, in some few
instances, that chlorosis co-existed with this disease of the stomach; but in
others, the females are described as having been stout and healthy. Besides,
the same disease, with the same characters, occurs in male subjects at various

Pathological Anatomy and General Pathology. 441

periods of life. — Evidence is then wantin]^ to show that there is any connection
between xihlorosis and a tendency to this disease of the stomach.

“ 3. I'he individual is suddenly seized with the most severe pain in the abdo-
men, generally soon after a meal. It seems probable that this pain takes place
at the moment the parietes of the stomach give way, and the contents of the
organ are effused into the peritoneal cavity. The pain is of that excruciating
kind, that the individual feels, unless it be removed, he cannot long survive.
The attack coming on soon after a meal, may be, perhaps, dependent on the
coats of the organ having become so thinned at the spot, that the slight action
required for chymification may lead to the entire destruction of the thinned peri-
toneal tunic, which at this time must form the only partition between the cavity
of the stomach and that ol the peritoneum. At other times, the occurrence of
the attack under these circumstances seems to be a pure coincidence; as where,
for instance, in one of the cases, the perforation took place immediately after a
cup of tea had been swallowed. We cannot be surprised, however, that poison
should be suspected to exist in the food, when an individual, apparently in full
health, is suddenly seized with such alarming symptoms; and therefore the
greater caution is required in investigating the case. We ought to be well
aware of all the particulars, before we countenance, in the least degree, the sus-
picion of poisoning: and among the diagnostic marks of the disease, we must
not therefore forget the*suddenness of the occurrence, and the interisity of the
pain.

“4. In several of the cases reported, pain in the abdomen was accompanied or
succeeded by pain between the shoulders. How far this deserves to be regarded
as a pathognomic character, must depend on further observation: but its having
been already so frequently met with, seems to render it something more than an
incidental occurrence. The pain in the abdomen commonly undergoes a remis-
sion before death; and the mental faculties are usually clear, until the last.

“ 5. There is commonly vomiting: this, however, is sometimes absent; and in
other instances very slight, the stomach simply rejecting what may be given as
medicine or food. There is no diarrhcea: in general, the bowels are obstinately
confined. The symptoms, after the first attack, when carefully examined, are
those of peritonitis, not of irritant poisoning.

“ 6. Death takes place in from eighteen to thirty-six hours: in most of the cases
mentioned, death occurred within twenty-four hours. The time at which the
disease proves fatal, closely approximates to that at which a person dies in
severe cases of arsenical poisoning.

“We may next direct our attention to the appearances met with in the dead
body.

“1. On opening the abdomen, there are all the marks of severe peritonitis;-—
etfusion of serum, with coagulable lymph; agglutination of the viscera; and
extravasation of the contents of the stomach.

“ 2. An aperture in the stomach, of an oval or rounded form; its shape depend-
ing, in some degree, on the manner in which the parietes of the stomach are
placed, to observe it. It is commonly from half an inch to an inch in diame-
ter; and is situated in or near the lesser curvature, between the cardia and
pylorus. This almost constant situation of the ulcerated aperture is a circum-
stance worthy of remark. It has not, as yet, so far as I am aware, received
any explanation from pathologists. The edges of the aperture are smooth, soft,
and fleshy-looking. The tunics appear to be thinned off, from within outwards;
so that the mucous membrane is usually removed to a greater extent than the
muscular coat; and this, than the peritoneal coat. The last is thinned off to a
sharp edge, so that there is no appearance of laceration or ulceration. Near the
circumference of the aperture, the coats of the stomach are thickened, some-
times hard, and even cartilaginous. This thickening may be disposed in a
slight ring, or extend to some distance; and it may he confined to one part of
the circumference, or extend all round. I have here described what I have actu-
ally seen; and although I do not presume to say that these are the invariable,
characters of the perforation, yet they agree closely with the descriptions given

442

Progress of the Medical Sciences.

by other and more experienced observers than myself. The hardeninor and
thickening of the parietes of the stomach, around the aperture, seem to indicate
what Andral long ago stated — that the ulceration is of a chronic character. The
smoothness of the borders of the aperture renders it {Probable that the tunics are
gradually thinned off by slow absorption; and that before the perforation is com-
plete, the peritoneal coat is reduced to the thinnest stratum of membrane. Were
it not so, we should expect to find the margin always fringed and lacerated; —
an appearance which is not, I believe, very usually observed. The peritoneal
coat does not seem to have undergone laceration or rupture, but to have become
entirely removed. In some cases, where this fringed appearance has been met
wdth, the circumstance may probably be explained by some mechanical cause
having accelerated the rupture of the thinned membranes. Dr. Abercrombie
thihks that the smoothness of the edges of the perforation is to be accounted for
by supposing them to have cicatrized.

“ When the aperture is the result of simple ulceration, then the appearances
will be modified: — there is no thickening of the coats of the stomach, and marks
of ulceration are apparent. The edge of the aperture may be very slightly or not
at all raised above the surface of the surrounding membrane. Several cases of
this kind have been adverted to, and are illustrated by the Museum preparations.

“ Sometimes there are two openings in the stomach, near each other: or, instead
of the second opening, there may be marks of ulceration scattered over the organ.

3. The mucous membrane of the stomach is either pale, or presents slight
patches of inflammatory redness over its surface: sometimes the margin of the
ulcerated aperture is slightly reddened, the other parts of the stomach being
healthy. — Guy's Hospital Reports, April, 1839.

9. Disorders of the Brain connected with Diseased Kidneys. — It has long been
familiar to the profession that suppression of urine is productive of disorder of
the brain, and that mechanical obstruction to the flow of urine is followed by a
similar result; and further, Dr. Bright has shown that there exists in many
instances, a corresponding connection between disorder of the brain and the
peculiar change of kidney to which his name has been bestowed. To Dr. Wil-
liam Addison, the merit is, however, we believe due, of being the first to make
the attempt to specify with precision, and in detail, the several forms of cerebral
disorder arising in connection with disease of the kidney, or to found upon the
character of these cerebral affections, a means of diagnosis available in cases in
which, from the absence of the ordinary symptoms of nephritis, of every form
of dropsical effusion, and of an albuminous state of the urine, the diseased con-
dition of the kidneys is liable to be altogether overlooked. The experience and
observation of this pathologist have led him to believe that such cases are by
no means of very rare occurrence, and that, in the absence of other indications,
the renal disease may occasionally be recognised with tolerable certainty by the
character of the cerebral disorder alone.

According to his experience, the “general character of cerebral affections con-
nected with renal disease is marked by a paleface, a quiet pulse, a contracted or
undilated and obedient pupil, and the absence of paralysis: — this general character,
however, being somewhat modified, in certain cases, by circumstances attending
the individual attack.

So far as Dr. A. has yet been able to observe, the individual forms of cerebral
disorder connected with renal disease are the five following: —

“ 1. A more or less sudden attack of quiet stupor i which may be temporary and
repeated; or permanent, ending in death.

“ 2. A sudden attack of a peculiar modification of coma and stertor; which may
be temporary, or end in death.

“ 3. A sudden attack of convulsions; which may be temporary, or terminate in
death.

“ 4. A combination of the two latter; consisting of a sudden attack of coma and
etertor, accompanied by constant or intermitting convulsions.

“ 5, A state of dulness of intellect, sluggishness of manner, and drowsiness, often

Pathological Anatomy and General Pathology, 443

preceded by giddiness, dimness of sight, and pain in the head; proceeding either
to coma alone, or to coma accompanied hy convulsions; the coma presenting the
peculiar character already alluded to.

“ With respect to the first-mentioned form of cerebral disorder connected with
renal disease, that of quiet stupor, it is, in its most exquisite form, probably the
least frequently met with; the face is pale, the pulse quiet, the pupil natural, or
at least obedient to light; and although the patient may lie almost completely
motionless, there is no paralysis; for, on attentively watching him for some
time, he will be observed slightly to move all the extremities. By agitating
him, and speaking loudly, he may sometimes be partially roused for a moment,
but quickly relapses into stupor, as before; or it may not be possible to rouse
him at all. There is little or no labour of respiration, no stertor, and no con-
vulsions. Slight degrees of it occasionally precede and pass into the next or
second form.

“ This second form of cerebral affection is that of a sudden attack of coma with
stertor, or in other words, apoplexy: it is, nevertheless, different from ordinary
apoplexy: it is the serous apoplexy of authors, and presents the usual general
characters of cerebral affection depending upon renal disease; for the face,
instead of being flushed, is, in almost every instance, remarkably pale; the
pulse, though sometimes small, and more rarely full, is remarkably quiet, or
almost natural; the pupil, also, although occasionally dilated or contracted, is
often remarkably natural in size, and obedient to light; and there is no paralysis.
When the labour of respiration is very great, the general character is apt to be
modified by an accelerated pulse, and occasionally by a slight flush of the coun-
tenance. The coma is for the most part complete, so that the patient cannot be
roused to intelligence for a single moment. The stertor is very peculiar, and in
a great measure characteristic of this form of cerebral affection connected with
renal disease: it has not, by any means, in general, the deep, rough, guttural, or
nasal sound of ordinary apoplexy: it is sometimes slightly of this kind; but much
more commonly the stertor presents more of a hissing character, as if produced
by the air, both in inspiration and in exspiration, striking against the hard palate
or even against the lips of the patient, rather than against the velum and throat,
as in ordinary apoplectic stertor; the act of respiration, too, is usually, from the
first, much more hurried than is observed in the coma of ordinary apoplexy.
The peculiar stertor coupled with the pale face has, in more instances than one,
enabled me to pronounce with confidence the disease to bereftal, without asking
a single question, and in cases, too, in which no renal disease whatever had for
a moment been suspected.

“The third form of cerebral disorder connected with renal disease is that of a
sudden attack of convulsions. In this case, also, the countenance is, for the
most part, remarkably pale, although, occasionally, slightly flushed at intervals:
the pupil is often but little affected: in slight attacks of the kind, the pulse is
sometimes singularly quiet; but when the convulsions are severp, and especially
when there is such a degree of coma as to be attended with stertor, the heart
often sympathizes, and the pulse becomes rapid, irregular, and jerking. This
form of cerebral affection often passes into the fourth variety; or the cerebral
affection shall take on the form of the fourth variety from the commencement;
in the latter case, we have merely a combination of the second and third varie-
ties— the coma, hurried breathing, stertor, and convulsions being so blended
together, as often to have led to a dispute, w'hether the affection ought to be
designated apoplexy or epilepsy. From what has been already stated, it may
in general be very easily recognised as one of the common forms of cerebral dis-
order connected with renal disease.

“The fifth variety is that in which the cerebral disorder makes its approach in
a more gradual and insidious manner, usually commencing with dulness of
intellect, sluggishness of manner, and drowsiness, gradually proceeding to coma,
and more or less stertor, with or without convulsions; these states being, at the
same time, distinguished by the general indications already pointed out. This
form of cerebral disorder appears to be that which most commonly supervenes

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Progress of the Medical Sciences,

in the progress of the morbid change of kidney described by Dr. Bright; and is
very frequently preceded by giddiness, dimness of sight, and pain in the head.”

Dr. Addison thinks, that he has perceived a certain degree of relation between
the actual condition of the kidney and the character of the cerebral affections.

“Of all the more serious affections of the brain arising in connection with
renal disease, the mildest form,” he observes, “ appears to be that of a tendency
to a state of quiet stupor, varying in degree from a mere torpidity of manner and
sluggishness of intellect, to complete insensibility to all surrounding objects.
Accordingly, I have found this form of cerebral disorder most frequently present
in what may be regarded as the least formidable, or more temporary derange-
ments of the kidney. The most exquisite example I ever saw, occurred in a
man who at the time presented no dropsical symptom whatever, whose urine
was not albuminous, and who made no complaint of pain or uneasiness in his
loins. After death, the cortical part of the kidneys was found highly injected,
of a deep-red or almost chocolate colour, and somewhat softened in its texture;
in short, furnishing the strongest indications of a recent nephritic attack in a
subdued form: it is also my belief, that tbe same state of things not unfrequently
takes place, at an early period, in the progress of scarlatina: we observe an
approach to a similar condition of brain in cases of fever, in which the bladder
has been allowed to become over-distended; and most assuredly in cases of
retention from stricture, and in cases of calculus in the kidney. In all these
instances, the interruption or impediment to the urinary secretion may be said to
be recent or incomplete; and hence, probably, the less degree of severity of the
cerebral affection, and the less peril to the patient; for in such instances the
symptoms very commonly pass away, and the patient recovers. When, how-
ever, the hurtful cause is of an originally nephritic character, the chance of
recovery will be less than when the cause of obstruction happens to be merely
mecbanical and temporary.

“ The next, in point of severity, of the cerebral affections connected with renal
disease appears to be that of convulsions, with comparatively little stertor; —
convulsions, however, which may prove speedily fatal; or which may be repeated
an indefinite number of times, but from which the patient very often completely
and permanently recovers. Accordingly, I have observed this form of more
simple convulsions most frequently associated with what may fairly be regarded
as a more exquisite and enduring form of renal disease than that just alluded to:
1 have observed it most frequently in cases of renal dropsy, subsequent to scarlatina;
and in that form of renal dropsy supposed to arise from direct exposure to damp
and cold, commonly known by the name of inflammatory dropsy. As the renal
affection has already proceeded to induce dropsy, we cannot but regard it as
more fixed and more formidable than in the cases described as being attended
■with more or less of quiet stupor: and accordingly, instead of merely a certain
degree of this latter condition, we have convulsion which may indeed prove
fatal, but from which, as already observed, the patient often completely and per-
manently recovers.

“As might have been expected, the most stubborn and intractable, as well as
the most fatal cases of cerebral disorder connected with renal disease are
unquestionably these found associated with the chronic and irremediable disor-
ganization of kidney described and illustrated by Dr. Bright. . It is nevertheless
very far from being true, that every such case of renal disease is associated
with cerebral disorder: on the contrary, in no very inconsiderable proportion of
such cases, even till the period of their fatal termination, no cerebral derange-
ment whatever, or, at least, none of sufficient intensity to attract particular atten-
tion, has been observed. Why cerebral symptoms should supervene in one
case and not in another, or, in other words, what it is that determines their
development in this and in other forms of renal disease, it is impossible, in the
present state of our knowledge, to ascertain; for, although a simultaneous dimi-
nution of the urinary secretion may occasionally be observed, such a coincidence
is by no means constant; the secretion, in some instances, continuing to flow in

Maleria Medica and General Therapeutics, 445

a very fair quantity, even at the period of the most formidable attacks of cere-
bral disorder.

Considering the gravity, permanence, and irremediable nature of the disorga-
nization in this form of renal disease, we might naturally expect that the cere-
bral disorder, -when it does supervene, would, in its constancy, urgency, and
irritability, be found in some measure to correspond;— and, accordingly, this has
really appeared to me to be the case; the patient suffering repeatedly, or more or
less constantly, from heaviness, drowsiness, giddiness, or pain, or sense of
tightness in the head, and being peculiarly liable to be suddenly seized with
the most alarming and most fatal of all the forms of cerebral disorder occurring
in connection with renal disease — profound coma and stertor, with or without
convulsions.

I have purposely omitted to notice the morbid changes discovered in the brain
after death: they are well known to be very often, in appearance al least,
extremely slight; and do not, as far as we are yet aware, either in their kind,
degree, or situation, offer any explanation of the form or severity of the cerebral
disorder which proved the immediate cause of death. — Ibid.

MATERIA MEDICA AND GENERAL THERAPEUTICS.

10. Employment of Sulphate of Quinine in the form of ointment for the cure of
malignant intermit tents. Dr. Antonini, principal physician of the French Army
in Africa, extols the efficacy of sulphate of quinine employed in the form of oint-
ment in the cure of malignant intermittent fevers. The following is his formula
for the preparation of this ointment:— Take of sulphate of quinine ^j., alcohol
38° to 40° q. s. (about §ij.,) acid, sulphur, q. s. (aboutSO drops) axung. .^iv. It is
essential that the solution in alcohol be complete and filtered, and that the mix-
ture be made gradually and with care, otherwise the quinine returns to its
original condition and its absorption does not take place. The usual quantity
employed at one time is about half an ounce of the ointment, but this dose may
be doubled in severe cases.

The mode of applying it is by frictions to the groins and it is also placed
in the axilla.— /owrn. des Connaiss. Med. Chirurg. Oct. 1838.

11. Formulse for Syrups of Copaiba. — M. Emile Mouchon of Lyons gives the
following formula for the preparation of a magnesian syrup of copaiba: — R.
Bals. Copaib. §iv; Magnes. Calc. gr. xxxij; Ess. Menth. pp. gtt. Ixiv; Syrup.
Simp. ^!x. Dissolve the magnesia in the balsam of copaiba, and when the
solution is complete, add the essence of mint and the simple syrup, triturating
them together for a long time. This preparation M. Mouchon states has nearly
the appearance of orgeat syrup, and with but little of the taste of the copaiba.

The following is the formula for the gummy syrup of copaiba of Dr. Puche.
R. Bals. Copaib. ^ij; Pulv. gum Arab, ^ss; Aq. Purse giss; 01. Menth. pp.
gtt. xxxij. Syr. Simp. ^xij. The balsam of copaiba is to be rubbed up with
the water and gum arabic, then the essential oil, and finally the syrup is to be
added. An ounce of this syrup contains a drachm of the copaiba. It is said to
be better borne by the stomach than other preparations of copaiba. — Journ. des
Connaiss. Med. Nov. 1838.

12. On Remedial Rowers of Croton Oil. By G. G. Sigmond, M. D. — The
remedial powers of croton oil have been made an object of the most elaborate
experiments, both internally and externally. Andral, Constant, Dr. Short, Dr.
Hutchinson, of Nottingham, have given us the result of close investigation, and
the medical profession are generally convinced of its great efficacy. It may be
rendered a iriild and gentle purgative, and if given with proper precaution is as
safe as any of the class with which we are in the habit of treating disease. It
is best administered in the form of pill, in union with compound extract of

No. XLVllL— August, 1839. 38

446 Progress of the Medical Sciences,

colocyntti, with the extract of jalap, or with extract of rhubarb, to which a drop
or two of the essential oil of cloves, of cinnamon, or of peppermint is added to
disguise its odour, and to prevent any griping. In cases where a pill is difficult
of deglutition a drop diffused in olive oil, or in a teaspoonful of syrup, may be
given, but this is ordinarily succeeded by a sensation of burning in the mouth,
along the oesophagus, and sometimes nausea; and even vomiting, but as soon as
these have subsided, which is usually in a few minutes, no uncomfortable sensa-
tion occurs till about an hour, or an hour and a half afterwards; then there are
slight colicky pains, and soon after evacutions take place; they at first come away
rather suddenly; in many instances the stools are watery, with a slight tinge
of yellow; at other times, and this frequently where the bowels have most deter-
minedly refused to obey the suggestions of other active remedies, the most
copious evacuations occur. A very singular and interesting case of tetanus is
narrated by Mr. Lawrence in his lecture on tetanus, which is to be found in The
Lancet for the year 1829, in which aperients did not produce the expected effect,
until the patient took a single drop of croton oil in a teaspoonful of light gruel,
and within about an hour a most violent action was produced on the bowels; he
discharged such a quantity of matter of various kinds from them, as altogether
astonished him, and all those about him, they seemed to be quite at a loss to
know how to describe the quantity. A case in which oxalic acid had been taken
as a poison is related by Mr. Lovegrove of Upper Baker-street, in which two
scruples of jalap and eight of calomel, an injection of castor oil, and of sulphate
of magnesia, produced only trifling evacuation, but a drop of the croton with
Jalap procured several free motions. One of the great advantages attendant
upon the administration of this, and of elaterium, where proper care has been
taken is, that they leave no bad effect whatever behind them, and that on the
following day the effects are quite over, the tongue wears its wonted appearance,
there is no febrile rhythm about the pulse, no uneasiness about the abdomen,
which bears pressure very well; indeed it is not unusual to find that the patient
has a tranquil sleep during the night, with gentle perspiration, and the kidneys
slightly called into increased action. It has been recommended to give croton
oil to those who are habitually costive, and it has been stated on medical autho-
rity that it is of great use in keeping the bowels regularly open; a hint of this
kind in a clinical lecture from a highly esteemed professor, was the reason that
it was adopted in some of the quack pills of the day, but from the combination
with gamboge, and probably the carelessness with which these ingredients
were mixed together, a drastic cathartic was the result, which has proved very
hurtful. In the only instances, two in number, in which the oil was recommended
as a sort of domestic remedy, it was found after a time very capricious as to the
effects it produced, sometimes acting with great vigour, at others without giving
any relief. There are some persons who cannot take it at all, they are very
sick an ^ are rendered highly irritable, but there are few who are griped by it.
It is very apt to produce eruptions on the surface of the body when taken inter-
nally, more particularly about the mouth. There, however, seem to be indi-
viduals who are excessively susceptible to papulous eruptions about the lower
part of the face after taking opening medicine, which is commonly called “the
going off of the fever.” It is a subject well worthy attention, that even skin
diseases of long standing have followed upon the use of some vegetable remedies
which act upon the bowels, accompanied sometimes by an intolerable itching.
The connection between the internal secretions and the external are, indeed,
oftentimes strongly evinced, as is the case in the miserable state of itching
which occurs after jaundice, and v/hich sometimes is as the poet has said of
love, “nullis medicabilis herbis ” Croton oil has been strongly recommended
in cholera, and the interesting case of Dr. Tegart, related by himself, of his suf-
ferings from spasmodic cholera, and his recovery by the use of the oil, have
made an impression on the profession; but although it led to trials of its efficacy
we have no reason to look upon it in any very favourable light as a decided
means of cure of the disease.

In cases where the due nervous impression is not made upon the intestinal

447

Special Pathology and Special Therapeutics,

canal, as in apoplexy, epilepsy, tetanus, and mania, croton oil is a most import-
ant remedy, as well from its great intensity of power, as from the capability of
giving it in such minute quantities. In very severe cases of painter’s colic,
Andral tried it with great success; indeed some cases have been known, of the
most striking character, to yield in two or three days. Some doubts exist as
to the utility of giving it in paralysis consequent upon this disease, or arising
from unknown causes. Some inflammations have been treated by it, but they
seem not to have been relieved by the remedy, with the exception of some cases
of laryngitis; but even these were not benefitted until the external application was
ordered. Many disorders that owe their aggravated character to loaded bowels,
such as asthma, obstinate headache, apparent determination to the head, are
relieved by a drop of croton oil, which then produces abundant liquid evacua-
tions. A drop rubbed on the abdomen will produce purging, a slight smarting,
and a redness of the skin taking place, but if a larger quantity be used this is
followed by an eruption of small papulas which gradually wear the appearance
of pustules; some of these are surrounded by a red areola, and occasion no small
degree of suffering; at the end of about thirty hours these pustules are fully
developed, having a whitish opaque fluid; sometimes they are not completely
formed until the fourth day, they remain then for a day or two unaltered, they
then dry up and fall off; the pustules bear a strong resemblance to those of small
pox. Advantage has been taken of this power to use the oil as a counter-irritant,
and frictions have been made with a mixture consisting of ten drops to an ounce
of the oil of sweet almonds. The first trials were made in the Hospital of La
Pitie, and there paralysis, sciatica, affections of the digestive organs, received
relief from these frictions. The appearances will vary much according to the
number of drops, the time employed in rubbing them into the skin, and the parts
of the body on which the frictions take place. It is upon the face, the scalp, the
larynx, and the chest, that the influence is most strikingly exhibited; the
extremities seem less acted upon; where the abdomen has been the seat of the
action abundant evacuations have occasionally occurred; the armpits and the
thighs exhibit often a high degree of rubescence. When the face and scalp
have been thus treated, erysipelas has sometimes been observed, still no bad
symptom has arisen. Active inflammation of the larynx has been successfully
combatted at La Pitie by it, but the testimony of Dr. Hutchinson does not con-
firm the testimony in its favour, when the inflammation is of a chronic nature,
and as he observes, no practitioner could place confidence to it alone in active
laryngeal inflammation.

There is a valuable paper from the pen of Dr. Inglis, of Castle Douglas, in
The Lancet, on the external application of croton oil in cynanche trachealis, in
which he details facts exhibiting the good effects of this as a remedial agent in
regular croup. There is one circumstance which you must bear in mind, in the
employment of this counter-irritant, as well as tartar emetic, that you will very
probably have a high degree of irritation produced at some part considerably
distant from the seat of friction, and that the scrotum will more particularly be
affected. The skin of the genitals is very apt to become in a very irritable
state, and the itching is most distressing, and continues sometimes after all
action of the croton has ceased; the smarting, the tingling, and the heat at bed-
time are generally much increased; decoctions of elm bark, and of dulcamara
allay these sensations, as does creosote, but then they again come on, and some-
times more pertinaciously than ever. — Lancet, 21st July, 1838.

SPECIAL PATHOLOGY, AND SPECIAL THERAPEUTICS.

13. Puerperal Fever, — The term Puerperal, or Childbed Fever, although not
scientific or consonant to the nomenclature of other febrile diseases, cannot in
the opinion of Professor Osiandee, be well replaced by any other which has
been proposed, such ?ilS peritonitis puerperalis, metro-peritonitis, &c. The perito-

448

Progress of the Medical Sciences.

neum and the uterus may be quite free from inflammation, and yet the patient
may die from puerperal fever.

Often the disease commences as an attack of meningitis, or of erysipelas, or
of rheumatic swelling of the joints, &c. and, under any of these forms, it speed-
ily proves as dangerous and alarming as when the uterus and peritoneum are
primarily affected. For this reason. Professor Osiander prefers to retain the
old generic term of Puerperal fever, and of distinguishing its various species or
forms in the following manner, according to the seat and character of the predo-
minant local mischief.

1. Puerperal fever with peritonitis.

. . . . hysteritis and peritonitis.

. . . . meningitis.

. . . . pneumonia.

. . . , miliary fever.

. . . . erysipelas.

. . . . arthritic swelling.

, . . . milk abscess.

. . . . gangrenous inflammation of the exter-

nal and internal generative organs,
(metritis gangrenosa.)

10.

. . . . typhus fever.

The last-mentioned variety includes, according to this tabular arrangement,
all those cases of childbed fever, in which there is a suppurative inflammation
of the uterine and adjacent veins. It is by far the most formidable variety
of the disease, and is that which usually prevails epidemically at certain sea-
sons, more especially in large institutions. To apply the term peritonitis^ or
metro-peritonitis to it, is not only quite incorrect — seeing that often no genuine
traces of peritoneal inflammation are discoverable on dissection — but is likewise
most seriously hurtful, in consequence of the erroneous treatment which will
necessarily be recommended.

An impure condition of the atmosphere — attributable very often to an over-
crowded state of the wards in a lying-in establishment — is unquestionably one
of the most frequent causes of puerperal typhus. That this form of the disease
is of a miasmatic origin, and is communicable from one patient to another,
cannot be well disputed; and it therefore becomes the duty of the physician
and nurse to use all precautionary means to prevent the dissemination of the
miasm, by changing their own garments frequently, washing their hands, &c.
as well as by the employment of fumigations and other well-known means.

Much may be done in the way of prophylaxis of this disease, but very little
in the treatment of it, when it is once fairly established. There is perhaps no
form of fever so little under the control of medicine as puerperal fever; it is
only in the precursory and very early stages of the disease that the healing art
can be of any avail.

According to the researches of Osiander, inflammation and suppuration of
the uterine veins is by no means so generally present, as some authors might
lead us to suppose.

Inflammation of the lymphatic vessels seems to be of much more frequent
occurrence when the peritoneum has been inflamed, than phlebitis of the ute-
rine veins.

The latter is, however, by far, the most serious affection of the two. Abscesses
of the liver, of the lungs, and of the muscles and joints, are not uncommon
sequelae of uterine phlebitis, when the patient has survived the early stage of
the disease.

The following few cases illustrate some of the most generally observed cha-
racters of puerperal typhus.

Case 1. — Puerperal Typhus, fatal in 24 hours, with Peritonitis, and Suppura-
tion in the Uterine Lymphatics.

A woman, 27 years of age, was delivered in the Maternite Hospital, at a
time when childbed fever was very prevalent. For three days subsequently

449

Special Pathology and Special Therapeutics.

she went on very well; but, on the fourth day, she began to complain of pain
in the hypogastric region. The pulse, at this time, was frequent, but not full
or hard; and the patient was troubled with diarrhoea and tendency to vomit-
ing. An unfavourable prognosis was formed, in consequence of the great frequency
of the pulse. Thirty leeches were applied to the abdomen, and an ipecacuan
emetic was administered; an ounce of mercurial ointment was rubbed in upon
the inside of the thighs, and a sinapised hip-bath was used.

In the evening, the abdominal pain was less severe, but the pulse was still
rapid and small: the diarrhoea and nausea continued.

Next day, the abdomen was tympanitic, and very painful; the breathing was
hurried and uneasy; but there was no delirium, or mental confusion. Sina-
pisms and friction with the mercurial ointment were continued; but the patient
died in the course of the night.

Dissection. — The abdomen was found to contain a quantity of muddy serum,
blended with numerous flocculi of albuminous matter — the result, no doubt, of
peritoneal inflammation. Beneath the peritoneum, in the left iliac fossa, there
was a purulent infiltration into the cellular tissue: this extended upwards as
high as the kidney. The lymphatic vessels of the broad ligaments were filled
with pus; but the uterine veins seemed to be entirely sound.

Case 2. — Puerperal Typhus, with Suppurative Inflammation, in the Sub-peri-
toneal Cellular Substance, and in the Uterine Lymphatics.

A woman was seized, on the second evening after a fortunate delivery, with
shivering and abdominal pain. Upwards of fifty leeches were applied on the
hypogastrium; and fomentations and other means were used. But on the fol-
lowing day the patient was moribund, and she died in the course of the even-
ing: the abdomen had become exceedingly inflated.

Dissection. — The abdominal cavity contained some reddish-coloured serum;
and between the uterus and rectum a small quantity of consistent pus was
found. In the region of the cascum some purulent matter existed behind
the peritoneum. The lymphatic vessels, which accompany the spermatic veins,
were full of matter.

Remark. — We are inclined to believe that the inflammation must have, in this
case, commenced previously to delivery.

Case 3. — Puerperal Typhus, fatal in fifteen hours after Delivery; Peritonitis
and Suppuration of the Lymphatics: softening and Melanosis of the Lungs.

A young woman was admitted, in the eighth month of her pregnancy, into
the Lying-in Hospital on the 17th of June, at a timo when the childbed fever
was very prevalent. On the third day afterwards, she experienced abdominal
pain, and feverish excitement.

On the 25th, she was delivered of a dead child; and, on the following day,
she died.

Dissection. — The abdomen contained a large quantity of white matter; and
the lymphatic vessels on the sides of the uterus were filled with pus. The infe-
rior lobe of the left lung was softened, and of a black colour.

Case 4. — Puerperal Typhus, fatal in 50 hours; Peritonitis, and Suppuration
of the Lymphatics.

A middle-aged woman was seized, on the evening after her confinement, with
shivering. Next morning, she had abdominal pains; the pulse was exceedingly
quickened, and very easily compressed; there was slight diarrhoea; the lochia
were not much aflfected. Osiander formed a very unfavourable prognosis of the
case, in consequence of the extreme rapidity and feebleness of the pulse: he had
not seen one patient recover in whom this state of the circulation existed. As
he had found evil only to result from sanguineous depletion in any form, and
from the use of emetics, as recommended by some physicians, he contented him-
self with recommending the application of poultices to the abdomen, and of
camphor ointment around the pubes and to the thighs, and of warm injections
into the vagina. By the use of these means, the patient was somewhat easier
towards evening. Next day the abdominal pain was gone, and the pulse was

38*

450

Progress of the Medical Sciences,

not quite so rapid: five grains of ipecacuan were ordered to be given every four
or five hours; and the warm-baths were to be continued.

But soon afterwards she became gradually worse, and she died 68 hours after
delivery, and about 50 after the commencement of the feverish symptoms.

Dissection. — The abdomen contained some purulent serosity; and pus was
found in the uterine lymphatics, in the Fallopian tubes, and in the cellular tis-
sue of the pelvis.

General Rejlections. — Professor Osiander closes his memoir with a few re-
marks on the probable exciting, or predisposing causes of childbed fever. He
insists particularly on the pernicious influence of cold air on women in the puer-
peral state; and he attributes the lamentable frequency and fatality of the dis-
ease, in the large lying-in institutions in Paris and Vienna, to the continual
ventilation of the wards.

He mentions, that whereas it is almost constantly more or less prevalent in
these hospitals, it is comparatively rare in the Maternite at Gottingen, whose
wards are small, never crowded, and uniformly kept in a state of pleasant
■warmth. He is therefore of opinion that, if in lying-in establishments more
attention was paid to the warming of the wards, and to avoid the crowding of
many patients together, the epidemics of puerperal fever would be much less
frequent and fatal.

He has never seen any good eifects from the administration of calomel and
active purgatives in this disease. He recommends the use of saline and tonic
medicines; and he mentions that the application of large mustard poultices to
the mammae — so as to excite a powerful revulsion from the uterus — has in
several cases seemed to act more beneficially than any other means, which he
has employed. — Med, Chirurg. Rev. April, 1839, from Zeitschrift fur die ges. Med,

14. Belladonna Plaster in Nervous Palpitations^ Irritable Bladder, ^c. — Dr.
Simpson, of the York County Hospital, uses a belladonna plaster over the region
of the heart, to quiet violent palpitation; and Dr. Laycock says that he has
found the application very successful, especially in nervous palpitation. Dr. L.
states also that the belladonna plaster will relieve irritable bladder and neuralgia
or irritability of the rectum. The plaster should be made with the pure extract
spread on lint or leather, and applied moist to the sacrum or perineum. Dr. L.
thinks that an opiate plaster made with powdered opium and soap cerate, is more
efficacious than belladonna, especially in irritable bladder; it will, sometimes,
enable a person to rest undisturbed during a whole night. — Lond. Med, Gaz. 16th
March, 1838.

15. External Application of ColcMcum in Rheumatism. — Dr. Thomas Laycock
states that he has been led, by some theoretical speculations, to try a liniment
composed of equal parts of the tincture of the root of colchicum and of the tinc-
ture of camphor, in rheumatism, and the result was exceedingly satisfactory.
He has found the colchicum alone equally successful. The only notice, he
observes, that he finds of this method of using colchicum is in the Diet, de Mat.
Med. of Merat and De Lens, ii. 361. A Dr. Gumpert is there quoted (from
Rev. Med. i. 140), as having used the tincture of seeds of colchicum as a local
application in gout and rheumatism very successfully. The particular instance
of a clergyman is mentioned, who was confined to his bed for a month or six
weeks with the latter, and who was able to leave it on the fifth day after frictions
with the tincture of the seeds. From theoretical considerations. Dr. Laycock
thinks it will be found a useful application in gout as well as rheumatism.
Those who have corns, which are painful during atmospheric changes, will Dr. L.
says probably find the twinges of those delicate pedal barometers alleviated by
the topical use of some preparation of colchicum. Bursal rheumatism will, of
course, be most relieved by its use. — Lond. Med, Gaz. 16 March, 1839.

16. Lytta in Vesical Paralysis. By Thomas Laycock. — I believe it is well .
kno-wm that the tincture and powder of the melde vesicaioria, or cantharis, is very

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Special Pathology and Special Therapeutics.

tiseful in atony or paralysis of the bladder, especially of hysterical and aged
people. I have found, however, that an emplastrum lyitse applied to the loins Is
equally efficacious, and much more manageable. A female, confined to bed in
the last stage of laryngeal phthisis, could not pass urine without raising herself
upon her knees. She was at last too weak for the effort, and it became a ques-
tion how the difficulty could be surmounted. I recommended an emplastrum
lyttae to be applied to the loins or sacrum, until she felt able to empty the bladder
in the recumbent posture. In half an hour after the application she succeeded.
She lived for three or four weeks subsequently, and the plaster was in almost
daily use until she died. In most instances from one to two hours elapse before
the desired effect is produced; in hysterical retention about the latter period. The
plaster is useful in other cases. A man came to the hospital with a catheter in,
his bladder; he had not made water without it for three weeks. It was removed,
and an emplastrum lyttae applied to the sacrum for three or four hours; he never
wanted the catheter again, and went away in a week quite well. I am not aware
that this method of using the fly is mentioned by authors. — Ibid.

17. Case of Paralysis of the first and second Branches, of the Sensitive Root of
the fifth pair of Nerves, with remarks. By D. J. Corrigan, M. D., of Dublin.
Catharine Gonlding, set. 23, was admitted into the Jervis street Hospital, Dub-
lin, 24th October, 1838. Six months before this date, she fell on her temple
against an iron grate, and at the time felt a very acute pain in the part, with
numbness in the left side of the head and face. The pain having continued, and
her sight in the left eye having grown dim, she took some purgative medicine,
and after this she continued pretty well until about two months before admis-
sion, when the pain of the temple returned, followed by almost total loss of
vision in left eye. On admission, almost total loss of sight in left eye, with a
very sluggish iris, a clear and a dilated pupil. She suffered from thirst, loss of
appetite, and debility. Her bowels were confined; her tongue was white. The
treatment adopted was leeching the temples, blisters to the back of the neck,
and mercury pushed to active salivation These measures greatly alleviated
her symptoms, but on the 8th November there was a return of the pain in the
temple, with dimness of vision, and followed on the succeeding days by tingling
and numbness in the left side of the head, and extending down the face. A
blister to the side of the head alleviated these symptoms, and the sight of the
left eye continued to improve, but the numbness of face increased; and on the
10th December the following is the report of her state: —

She is slightly salivated (she had been using gr. iij. of pilula hydrargyri ter
in die). Over the left side of the scalp and in the ear there is undiminished
sensibility, as also in all the portion of the cheek, which is below a line drawn
from the angle of the mouth to the lobe of the ear. But in the left half of the
forehead, the left eyebrow, around the left eye, and in the anterior part of the
left cheek, and in the left half of the nose within and without, and in the left
half of the upper lip, there is total loss of sensation; so that in any of those
parts the skin may be pricked with a needle without her being conscious of it.
In the left half of the upper gum there is also total loss of sensation. In the
lower gum the sensation is duller than natural. There is no loss of muscular
power in the jaw or eyelid, nor any appearance of paralysis either when the
face is at rest or when she speaks. In the left temple there was a circum-
scribed spot, which was very painful on pressure, and which, when pressed
upon, gave her a shooting pain down the cheek. Over this spot she was leech-
ed every second day. Her sight improved, the pupil became -more active, but
the other symptoms remained as before, with the addition that on the 21st
December she complained of inability to move the jaw freely on the left side.
There is, however, no want of power in the left eyelid. The repeated leeching
has diminished the soreness of the temple and improved the sight very much,
and she is now rubbing the scalp with tartarized antimony and mercurial oint-
ment, and taking internally 10 grs. of hyd. c. magnesia ter in die.

This case is a valuable addition to our knowledge of the affections of the

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Progress of the Medical Sciences,

nerves of the face, which, until late years, w’as little better than a web of con-
fusion. To Sir Charles Bell we owe the first clue that has led us out of the
labyrinth; and the case before us, of Goulding, deserves a place among- those to
which we may refer as establishing the sureness of the foundation on which
our opinions of the functions of the nerves of the face now rest.

To understand the nature of Goulding’s case, it is necessary to recal your
attention to the anatomy of the fifth pair of nerves. There is in this case total
loss of sensibility of the left side of the forehead, of the left side of the nose, of
the left side of the palate, and of the gum of the left half of the upper-jaw, and
of the upper-jaw', and of the cheek, as low as the angle of the mouth; while,
below a line extending from the angle of the mouth to the lobe of the ear on
the same cheek, the sensibility is perfect. There is not the slightest loss of
muscular power in any part of the cheek; she has full power over the eyelidj
angle of the mouth, buccinator muscles, &c., whether in chewing, sneezing,
laughing, &c.

The anatomy of the fifth pair of nerves, will now explain to us this case,
which is one of those beautiful instances in which anatomy, physiology, and
pathology, mutually throw light on each other. The fifth pair of nerves consist,
you will recollect, of two roots; one the sensitive — the other the motor root.
The sensitive root, after having formed upon it the Gasserian ganglion within
the skull, sends off from this ganglion three branches; the first the ophthalmic
branch, which is distributed to the parts within the orbit, and which sends off
the supra-orbital branches to the skin and integuments of the forehead, with a
brush of smaller twigs which are distributed over the inner canthus of the eye
and the root of the nose, while the nasal branch is spread over the alae and tip
of the nose. The second branch, the superior maxillary, given off from the
Gasserian ganglion, leaves the skull through the foramen rotund um, and sends
along the infra-orbital canal, in the floor of the orbit — the infra-orbital branch,
which passing out to the cheek through the infra-orbital foramen, is then dis-
tributed to the anterior part of the cheek to the ala nasi, and twigs of it descend
as low as the external angle of the mouth; where they meet those coming up
from the foramen mentale. Other twigs of this second branch, the superior
maxillary, are distributed to the palate, the gum of the upper jaw, and the
interior of the nose.

I have now to turn your attention to the third branch of this sensitive root of
the fifth. This branch, setting out also from the Gasserian ganglion, leaves the
skull by the foramen ovale, in company with the motor root of the fifth pair.
This motor root, which has lain in the skull behind the Gasserian ganglion, has
as yet formed no junction with any portion of the sensific root; but having
passed out through the foramen ovale, in company with the third branch, it
then, in the pterygoid fossa, becomes intimately interwoven with this third
branch of the sensific root, and the compound nerve, thus formed, is the inferior
maxillary nerve. It is obvious that, according to this account of the anatomy
of the fifth pair of nerves, the ophthalmic and superior maxillary nerves being
given off by the sensific root of the fifth before any connection has as yet taken
place between the sensific root and the motor root, the ophthalmic and superior
maxillary nerves must be merely sensific nerves; and that in the event of disease
producing paralysis of these nerves, the effect on the parts supplied by them
ought to be loss of sensibility alone; and that, as these nerves cannot confer
motive power, muscular action should not be disturbed by paralysis of them;
and thus exactly we have it in the case before us. There is loss of sensibility
in all the parts of the face and interior of the mouth, supplied by those branches,
but no loss of muscular power. Thus anatomy and physiology explain to us
those symptoms which otherwise would be inexplicable, and again, pathology,
more beautifully than a thousand experiments, confirms the accuracy of our
anatomical observations, and the truth of our physiology of this nerve.

Sensation, we have seen, is perfect along the lower jaw below a line drawn
from the angle of the mouth towards the lobe of the ear. The parts below this
line, the skin of the cheek, the chin, and the gum of the lower jaw, are supplied

453

Special Pathology and Special Therapeutics.

by the third branch of the fifth, namely, the inferior maxillary nerve. Now,
does the preservation of sensibility in the lower part of the cheek, while it is
lost in the upper part — or, in other words, does the continuance of function in
the third branch of the sensitive root of the fifth, while it is lost in the first and
second branch, lead to any practical result in diagnosis and prognosis'? With
the light of anatomy it does, and to a very important one. It tells us that the
disease which has deprived the first and second branches of the fifth of their
function'of sensibility is not disease of the brain, nor, probably, has it its seat
within the cavity of the skull; for if the diseased action attacked the nerve pre-
viously to its forming the Gasserian ganglion from which all three branches
take their origin, then it would be nearly impossible that the function of the
third or inferior maxillary branch should not have been equally destroyed with
the functions of the other two. Were the disease within the skull, it is also
most probable that the motor root of the fifth, which in part of its course lies
in very close relation to the sensific root, should suffer equally. But as the
motor trunk and the third branch of the sensific trunk are not injured, we are
justified in concluding that the cause of the paralysis of sensibility of the first
and second branches has its seat external to the cavity of the skull, and the
diagnosis thus made leads of course to the more favourable prognosis. Thus,
anatomy and physiology here lead us both to diagnosis and prognosis. With
this instance before you, to show you the value of the observation, let me en-
treat of you never to lay aside anatomy or physiology in studying practical
medicine. How different now is our interest in this case, and how superior our
knowledge of it, when we have thus taught ourselves that even in disease the
symptoms which present themselves are not the result of mere chance, but are
in strict accordance with the laws of healthy action! If there were no other
result from this analysis of the symptoms of this case than the attractive inves-
tigation of some of the functions of the nervous system, and the conformation of
our physiological knowledge, this alone should make us study the symptoms
with enthusiastic interest; but when we find that on this analysis depends our
knowledge of the nature of the disease, its study then becomes a duty. There
is, I am sorry to say, a growing tendency to substitute what is called observa-
tion at the bed side for anatomical and physiological investigations of structure
and symptoms. Such a doctrine is very acceptable to the ignorant empiric and
the indolent student; but to expect to attain sound knowledge by such a course,
would be as reasonable as it would be in a mechanist to expect that he could
ever attain a knowledge of the derangements of a machine, without bringing to
his assistance a knowledge of its structure and its powers.

If we now turn our attention to the inferior maxillary nerve, the third branch
of the sixth, and to the portio dura of the seventh, we shall find in the physiology
of these nerves an explanation of some curious forms of nervous affections of
the face, and to which we find almost nothing analogous in any other part of the
body.

The first is that in which the seventh or portia dura alone is paralyzed.

I saw a lady some time since, whose features were undisturbed and free from
distortion when at rest, but when she laughed or smiled, the muscles on the right
side alone acted, while the left side of the face remained perfectly passive, thus
giving to the countenance the hideous expression of half of a living and of a dead
face being joined together. In such a case as this the paralysis is confined to the
seventh nerve, the motor branch of the fifth being unaffected. While the face
is at rest, the motor branches of the fifth at each side neutralize each other, and
there is no distortion; but on the seventh or portio dura being called into action
as a nerve of expression, the nerve of one side alone acts, and thus this singular
form of paralysis is produced.

In contrast with this may be placed a case of paralysis of the third branch of
the fifth, the inferior maxillary nerve. The case is from Sir G. Bell’s work on
the Nervous System.

A man affected with hemiplegia was paralytic of the right side of the face,
which was also insensible on being pricked with a needle.

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Progress of the Medical Sciences,

When at rest, the right side of the mouth and the right cheek hung down,
and the saliva constantly flowed from it. But when he was made to sneeze, to
laugh, or to whistle, the distortion disappeared, and both sides of the face acted
equally. Thus these cases are contrasted with one another. In paralysis of
the portio dura alone, there is no paralysis when the muscles of the face are at rest,
but it becomes most disagreeably evident by distortion on giving expression to
the face. In paralysis of the third branch of the fifth there is paralysis of the face
when at rest; but when a respiratory expression calls the seventh into action, the
paralysis for the time being disappears.

The most common form of paralysis of the face is when both the third branch
of the fifth and the portio dura are simultaneously aflected, so that there is para-
lysis both when the features of the face are at rest, and in the expression of
laughing, sneezing, &c. Such is the following case: —

Michael Keefe, admitted into this hospital December 3. About ten days
before, he felt his upper lip swelled, and next day perceived that, in attempting
to masticate, he could not turn the morsel in the right side of his mouth. On
admission his mouth was drawn to the left side; he was unable to close the eye-
lid of the right eye; he could not whistle, and when he laughed the left side of
the face alone acted. In this case both the seventh and the third branch of the
fifth of the right side were paralyzed, for there was in the case a combination of
the symptoms of the two former cases. There w’as inability to masticate, and
there was distortion of the face when at rest, dependent on paralysis of the
third branch of the fifth; and there was also distortion of the face in expression,
indicating paralysis of the portio dura.

We have thus the following form of local paralysis of the face: —

1st. Paralysis of sensibility, as in the case now in hospital, the muscular
power being unaffected — dependent on disease of first and second branch of the
sensific root of the fifth pair of nerves.

2d. Paralysis, not visible when the features are at rest, but most strongly
marked when any respiratory expression, such as sneezing, laughing, &c. is
attempted — dependent on disease of portio dura.

3d. Paralysis, persistent when the face is at rest, but temporarily suspended
when any respiratory expression is attempted — dependent on disease of the
third, or compound moto-sensific branch of the fifth.

4th. Paralysis of the face both at rest and in motion, in which both the portio
dura and third branch of the fifth are implicated.

For the experiments and some of the cases on which I^have grounded these
observations, I must refer you to Sir Charles Bell’s work on the Nerves.
There is, however, in some parts of that work an obscurity, and occasionally an
apparent contradiction, w'hich may render its perusal difficult. You will ob-
viate the difficulty by consulting Dr. O’Beirne’s analytical correction of Sir
Charles Bell’s work. It is published as an appendix to Dr. O’Beirne’s work
on Defaecation, and it will well repay you for a perusal. To return to our case
in hospital. I have already given my reasons, founded on the immunity of the
inferior maxillary nerve, for thinking that in this case the disease is not within
the cavity of the cranium, or at least between the Casserian ganglion and the
origin of the nerve. It is probable that the injury which this patient received
produced periostitis of a subacute or chronic form, and that this, creeping along
the temporal surface of the sphenoid bone, has also spread through the spheno-
maxillary fissure to the lining membrane of the orbit, and has then involved the
first and second branches of the fifth. This view is strengthened by the circum-
stance of there being still a small space in the upper part of the temporal hol-
low which is painful under pressure. 1 shall therefore, for some time longer,
continue the same line of treatment under which he at present is, viz. repeated
local blood letting and blistering, and the exhibition of a mild course of mercury.
The head symptoms, the vertigo, &c. have ceased, the motion of the pupil has
become natural, and the sight is much improved, so that we have to contend
with only the local tenderness in the temple, and the loss of sensibility of the
first and second branches of the fifth.

455

Special Pathology and Special Therapeutics.

P. S. — Since the above was delivered, numbness, accompanied with loss of
power, began to extend to the lower jaw, showing that the diseased action was
beginning to implicate the third, or compound branch of the fifth. The whole
head was then rubbed over with antimoniated mercurial ointment and iodine;
the amendment was rapid, and she soon after left the hospital with scarcely a
trace of the disease. — London Medical Gazette^ 30th March, 1839.

18. Pathology and Treatment of Phlegmasia Bolens. — By John Burne, M. D.
(Extracted from Clinical Lecture delivered at the Westminster Hospital.) In
the case of Mary Wiggins, there took place about the fifteenth day of her illness,
while she was lying on the back in a state of the greatest prostration and danger,
a more or less hard though oedematous swelling of the whole of the left lov;er
extremity from the groin doMmwards, the swollen limb being white, varied,
however, with numerous minute veins in the skin, while none such were appa-
rent in the other limb. The whole of the limb affected was rather tender to the
touch, and painful; but the chief pain and tenderness were seated in the groin
and antero-inlernal region of the thigh, where could be felt the femoral vein like
a hard cord or bougie, the size of the little finger. The femoral artery pulsated
normally on the outer side of this cord-like vein.

Here was a well-defined example of phlegmasia dolens, such as occurs in
childbed women. It was distressing to find this disease showing itself at a
moment when the exhausted powers of the patient were altogether unequal to
cope with any fresh obstacle to recovery, and when, consequently, one could not
but expect that it would turn the balance fatally against her.

On account of her prostrate condition it was impossible to have recourse to the
local abstraction of blood by leeches — the usual treatment of phlegmasia dolens,
nor did any but a soothing treatment suggest itself. While considering this point,
Mr. Hale Thomson joined us in the ward, and remarked that he had found benefit
in a similar case by suspending the limb from the top of the bedstead, so as to
allow the venous circulation of the extremity to be favoured by gravity. The
suggestion I adopted at once, and attempts were made to suspend the linlb; but
the position was insupportable, and the foot and leg, therefore, were merely
elevated a few inches on pillows. The effect of even this elevation was, how-
ever, most satisfactory. The pain and also the oedematous swelling began to
subside forthwith, and the amendment continued uninterruptedly from this period;
the cord-like state of the femoral vein diminishing, and the oedema passing away
from day to day, till at length complete recovery was effected.

It is only within a very recent period that the pathology of phlegmasia dolens
has been understood, it having been established by Dr. David Davis, in an able
essay read before the Royal Medical and Chirurgical Society in May, 1823, and
published in the twelfth volume of the Society’s Transactions.

Prior to the discovery of Dr. Davis four theories of the cause and nature of
this affection were entertained: —

1. By Mauriceau. “A reflux, determined to those parts of humours, which
ought to be evacuated by the lochia:” Also, by Mesnard. “ Suppression of
the lochia, producing an over-fulness of the Ijlood vessels, and a consequent
arrest and coagulation of lymph in the parts affected.”

2. By Puzos. “The celebrated doctrine of metastasis of milk- — depots de lait.^^

3. By W hite and Trye. “ Obstructions or other morbid states of the ly myphatic
organs of the parts affected.”

4. By Dr. Hull. “The proximate cause consists in inflammatory affection,
producing suddenly a considerable effusion of serum and coagulated lymph from
the exhalents into the cellular membrane of the limb. The seat of the inflamma-
tion I believe to be in the muscles, cellular membrane, and inferior surface of
the cutis. In some cases, perhaps, the inflammation may be communicated from
these parts to the large blood-vessels, nerves, and the lymphatic vessels and
glands imbedded in them.”

All these conjectures — they scarcely deserve the name of theories— were dis-
proved by the pathological investigations of Dr. Davis, who discovered that

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Progress of the Medical Sciences.

the large veins of limbs affected with phlegmasia dolens were obstructed by
coagula, which adhered to the sides of the veins, and inferred from these appear-
ances, and from the symptoms during life, that inflammation of the veins and
consequent obstruction was the proximate cause of the phlegmasia dolens. The
white cedematous swelling is merely a dropsical state of the limb resulting from
the venous obstruction, the usual cause of local or partial dropsy or oedema.

The cases of Fearn and Wiggins— both true examples of piilegmasia dolens —
were characterized by the pain and tenderness in the course of the lar;^3 veins in
the groin — by the cord-like feel of these veins — by the soreness and white cede-
matous swelling of the whole extremity — symptoms which left no doubt of there
being inflammation and obstruction of the veins. In the case of Fearn, who
died, we had an opportunity of dissecting the affected limb; and the preparation
now before you exhibits the vein and artery taken from it. You here see the
common and internal iliac and femoral vein, filled with red coagulum adherent
to the sides of the veins, so as to block up the channels and obstruct the circu-
lation of blood through them; thus agreeing with and confirming the dissections
and opinions of Dr. Davis, viz: that inflammation and obstruction of the iliac
veins and their contributory branches are the cause of phlegmasia dolens.

So far the pathology of phlegmasia dolens may be considered as established;
but there is one very important point not yet made out, viz: the cause of the
infammation of the veins.

How is it, and why is it, that these particular veins, the iliacs, become affected
with inflammation^ What excites or induces inflammation in them especially!
The cases of Fearn and Wiggins, under consideration, will, I think, afford a
satisfactory answer and explanation.

The phlegmasia dolens in both these cases occurred under exactly similar cir-
cumstances, both patients being reduced to an extreme degree of prostration, and
both lying upon the back, with the limbs outstretched and motionless, which
appeared to me so far remarkable as to suggest the notion that both may have
depended on a similar cause, and that this possibly was a stagnation of blood in
these veins resulting from the languid powers of the venous circulation, pro-
ducing first congestion, then inflammatioD, obstruction, and csderna — symptoms
collectively constituting phlegmasia dolens.

Again, it struck me as remarkable that, in both these patients, the same limb
— the left — was the seat of the affection. This led me to inquire how far any
anatomical relations or peculiarities of the iliac veins of the left side, as com-
pared with the right, might exist normally, and aid in retarding the circulation,
in the very weak state of these patients. In this inquiry, it certainly does
appear that the normal situations of the aorta and cava, and of the iliac arteries
and veins, is such as to render the circulation in the left iliac less free than
in the right; and although, with this natural arrangement, the circulation of
the left iliac may be perfect under the ordinary circumstances of health and
exercise, yet, when the powers of life have been reduced to the lowest degree,
and when there is an entire absence of all muscular motion, a great aid to the
circulation of the blood in these veins, I can then understand that the slight
greater difficulty in the circulation of the left iliac might so impede the circula-
tion in this vein as to be the cause of congestion; the congestion, the cause of
irritation; the irritation, of inflammation; the inflammation, of complete obstruc-
tion; the complete obstruction, of the oedema.

The anatomical relations above alluded to depend particularly on the situation
of the right common iliac artery and the left common iliac vein, which cross each
other like the letter X.

You will remember that the vena cava inferior lies on the right lateral part of
the bodies of the lumbar vertebrae, and that consequently the left common iliac
vein, in order to reach the cava, has to traverse the body of the last lumbar
vertebra, and in this course passes directly under the right common iliac artery;
for the aorta being situated on the left lateral part of the bodies of the lumbar
vertebrae, the right common iliac has also to traverse the body of the last lumbar
vertebra, in order to reach its destination, the right extremity; and in this course

457

Special Pathology and Special Therapeutics,

passes anterior to the left common iliac vein: the vein and artery crossing each
other like the letter X, on the body of the vertebra. In this arrangement, the
left common iliac vein, as it traverses the vertebra, is subject to pressure from
the right common iliac artery, and to counter-pressure from the unyielding ver-
tebra; and when it is remembered that the arteries during life are always full,
distended, and cylindrical, it is not unreasonable to believe that the vein, placed
between the artery on one hand, and the vertebra on the other, and traversed at
an acute angle by the artery, is subjected to more or less pressure, and the cur-
rent of blood along the vein more or less impeded; an impediment, however, of
no moment, except when the powers of the body and of the circulation have been
reduced to the lowest ebb, when every trivial difficulty or obstacle proves insnr-
mountable. Moreover, the position in which the patients Fearn and Wiggins
lay — namely, on the back, with the legs straight and extended — would, by put-
ting the artery on the stretch, determine pressure on the vein; for the arteries
taking the shortest course, and being elastic, longitudinally as well as trans-
versely, are stretched when the limbs are extended, and relaxed where they are
bent.

This view is borne out by the treatment which, in the ease of Wiggins, was
found to be efficacious— namely, the elevation of the limb; which had the double
effect of favouring the return of blood by giving the venous circulation the
advantage of gravity, and of relaxing the iliac artery, and so removing whatever
impediment may have been offered b^y it.

Now, gentlemen, having concluded, from the comtemplation of these two
cases, that the anatomical relations of the large blood-vessels of the left extremity
were in part the cause of the phlegmasia dolens, and were the reason why the
disease took place in the left rather than in the right extremity, I was curious to
ascertain how far the eases recorded by others agreed in this respect or otherwise;
for if the above opinion is well-founded, the phlegmasiai dolens ought to occur
in the left rather than in the right extremity: this I find* to be exactly the case.
For example.

One ease, recorded by Zinn, occurred in the right only.

Four cases are recorded by Dr. Davis, and in all of these the left was the
extremity affected..

Five cases are recorded by Dr. Lee, in all of which the left extremity was
affected. In one, the right was affected also.

Three cases are recorded by Velpeau, in all of which the left extremity was
affected. In two of these, the right was affected also.

Seven cases are recorded by Bouillaud, in all of which the left extremity was
affected. In three, the right was affected also^

No. Case. Extremity.. Extremity.

1. — 1. By Gottfrey^ Zinn - - - - Right.

2. — I. By Dr. D. Davis - - - - Left.

3. — II. - — Left.

4. — III. “ - Left.

5. — IV. “• - Left.

6. — I. By Dr. Lee Left.

7. — II. “ ----- Right and Left.

This case commenced with varicose veins in right extremity during
the last two months of pregnancy.

8. — III. Left.

9. — IV. « Left.

10.— V. “ Left.

11. — I. By Bouillaud, from pressure of a tumour

12. — II.

13. — III.

14. — IV. “ “ from Fievre ataxique -

No. XL VIII.— August, 1839. 39

Right and Left.
Right and Left.
Right and Left.

Left.

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Progress of the Medical Sciences,

No. Case.

Extremity.

15. — V. By Bouillaud from phthisis

Left.

16.— VI. “

abscess

—

Left.

17.— VII. “

phthisis

—

Left.

18. — I. By Velpeau

—

Left.

19.— 11 “

Right and Left.

In this case there was abscess in

the body of the uterus.

23.— Ill

Right and

Left.

SUMMARV.

Right only.

Left only.

Right and Left.

Total.

Zinn

Davis

Lee

Bouillaud

Velpeau -

By a further analysis of these cases, we shall find that, in nineteen out of the
twenty the left extremity was affected; but in six of these the right was affected
also. That in the twentieth case, where the right extremity only was affected,
the disease was produced by a special cause — viz: “some of the inguinal glands
scirrhous, greatly enlarged, and surrounding the femoral vein, by which its
diameter was very much diminished.”

That in the six cases, in which the right extremity was affected as well as the
left, there M^as a special cause, a tumour; in three, viz: Nos. 11, 12, 13, an
abscess in body of uterus; in one. No. 19, and in another. No. 7, the case com-
menced in the right extremity during the last two months of pregnancy, with
varicose veins. Whereas, in all the cases, except No. 20, which have occurred
after delivery, or which have not been produced by a special cause, the disease
has occurred in the left in preference to the right extremity.

That in three of the cases. Nos. 14, 15, 17, in which there was excessive pros-
tration of the vital powers, and which are, therefore, analogous to the cases of
Fearn and Wiggins, the disease took place, as in them, in the left extremity.

From all this evidence, then, it may be inferred, that phlegmasia dolens is
more generally seated in the left extremity, and almost universally so when it
happens under circumstances of great prostration of the vital powers, or after
delivery.

That where it is seated in the right extremity only, or in the right as well as
the left, there is some special cause, as tumour, &c., in operation.

Causes.— Although, then, we may, I think, be justified in believing that the
anatomical relations of the left iliac vein, and of the right iliac artery, may be
the cause of phlegmasia dolens in the left extremity, where the powers of the
body are very weak, we must not forget that other causes may lead to the same
result. During labour, for instance, it is the custom for women to lie on the left
side, often for hours together, most injudiciously; and the same position is fre-
quently maintained, even after delivery. Now, in this position, one can under-
stand that the left iliac vein may be subjected to pressure from the uterus, both
before and after delivery, and the venous circulation of the extremity be impeded,
and thus phlegmasia dolens be induced. So also may a similar effect be pro-
duced by an accumulation of faeces in the sigmoid flexure of the colon.

Whatever, then, impedes or obstructs the return of blood along the large
veins of either or of both the lower extremities, may be regarded as the remote
cause of phlegmasia dolens; and the three causes just enumerated appear to
determine the greater frequency of disease in the left than in the right lower
extremity.

The treatment^ according to the above views of the pathology of phlegmasia
dolens, should be based on the principle of removing or obviating the cause, and

459

Special Pathology and Special Therapeutics.

of facilitating the return of blood along the veins; for as the inflammation of the
veins has been shown to depend on congestion of blood from obstruction, it
would be injudicious to direct measures solely to the subdual of the inflammation
without reference to the cause of it. Besides, in cases, such as form the subr
ject of this lecture, where the powers of life are nearly exhausted, antiphlogistic
measures could not be pursued. The abstraction of blood, even by a single
leech, could not be justified. We have seen how efficacious and successful the
principle of treatment 1 have just advocated was in the case of Wiggins, where,
by elevating the limb and thus relaxing the iliac artery, and at the same time
favouring the return of blood along the veins, the disease at once subsided with-
out any other aid. Now had not this treatment been suggested and followed,
we must have contented ourselves with the use of fomentations, for leeches were
not admissible; and it is more than probable that the disease, in her weak state,
would have turned the balance against her, and led to a fatal result, as in the
case of Fearn. This treatment is applicable in all cases, and will probably be
successful in those arising from debility, and auxiliary in the others, if adopted
sufficiently early; but if inflammation has already gone to such an extent as
entirely to obstruct the large veins, then its success will be less complete.

You must bear in mind the absolute necessity of ascertaining the cause, and
of endeavoiii ing to remove it. If the cause was pressure of the womb, remove
it by change of position; if pressure from a loaded state of the sigmoid flexure
of the colon, evacuate the bowels; if pressure from a tumour, attention should be
directed to it; and as the cause admits of removal or otherwise, so will the cure
be easily or with difficulty effected.

As regards the phlebitis, or inflammation of the veins, it will subside if the
circulation can be restored by a relaxed and elevated position of the limb; but
if, for reasons before mentioned, it should continue, as indicated by tenderness
and pain in the course of the veins in the groin, then local blood-letting by leeches
should be had recourse to as far as the strength will permit. Dr. Davis is of
opinion that general bleeding is “decidedly objectionable,” in which I entirely
agree. He suggests gentle bandaging — a plan w'orthy of a trial in cases where
there is no permanent cause, as a tumour.

The experience afforded by the cases of Fearn and Wiggins^ has enabled us to
arrive at the primary cause, and so to perfect the pathology of phlegmasia dolens,
by regarding the inflammation of the veins as secondary. It has enabled us also
to determine that the first object in the treatment should be to favour and facili-
tate the return of blood along the veins, which may of itself frequently attain the
second, namely, the subdual of the inflammation.

The pathology of the disease then stands thus:—

1. Congestion from some impediment. 2. Irritation. 3. Inflammation. 4.
Complete obstruction. 5. (Edema.

The principle of treatment: 1. To favour the return of blood by suspending oir
elevating the limb. 2. To combat the inflammation, if necessary, by local bleed-
ing, consistent with the strength of the patient.

Any of you who desire to make yourselves further acquainted with the dis-
ease, may consult Dr. Hull’s Essay on Phlegmasia Dolens, 1800; Dr. Davis’s
Essay in the 12th volume of the Transactions of the Medical and Chirurgical
Society; Dr. R. Lee’s paper in 15th volume of ditto; Velpeau, (Phlegmasia
Dolens,) Archives Generales de Medecine, tome vi; Bouillaud: Obliteration
des Veines; Archives Generales des Medecine, tome ii. p. 188. — Lond. Med.
Gaz. 16th March, 1839.

19. Treatment of Quinsy hy Scarification. By M. Gerardtn. — M. Velpeau,
in his Trait 'e d' Anatomic C^^V^^rg^c«/e, distinguishes two species of inflammation
in the tonsils, one limited to the mucous membrane, the other situated in the
submucous cellular tissue. It is important to recognize these two different seats
of the disease. The examination of the throat will be sufficient to determine
whether the mucous tissue or the cellular be attacked; and this diagnosis is
indispensable, since the treatment which may prove successful in the one case
would be detrimental in the other. Perhaps it is to the want of this distinction,

460 Progress of the Medical Sciences*

that the experience of one practitioner has been contradicted by another: for
instance, in the use of alum gargles; which have proved advantageous in ttie
mucous inflammations, but have increased the pain and inflammatory symptoms
in the parenchymatous disease.

The application of leeches to the submaxillary region occasions often a local
subcutaneous effusion in the neighbourhood of the inflamed tonsils; and it is to
he lamented that this remedy should still be the common routine prescription
with the generality of practitioners; for the physician is often called in only after
one or two applications of leeches have preceded him. In every quinsy, whether
mucous or parenchymatous, if the state of the subject be plethoric, I first bleed
from the arm, and some minutes afterwards, I proceed to scarify the inflamed
parts. It is rarely necessary to recur to this operation more than twice. In the
most intense parenchymatous quinsies the disease yields to two scarifications
made within twelve or twenty-four hours of each other. The swelling subsides
directly, the patient feels great relief, which he does not fail to express. The
scarifications are to be made more or less deep, according to the seat of the
inflammation; if the cynanche is mucous, I slightly scarify all the parts red-
dened by the inflammation, the tonsils, the palate, and the uvula: if the disease
is parenchymatous, I make deeper scarifications, particularly in the tonsils. I
puncture the surface as long as the flowing blood will permit me to see: and,
after it has cleared away, as the operation is not painful, I complete the
scarifications on the untouched parts. In the parenchymatous quinsy, twelve
or fifteen punctures will afford a sufficient bleeding. Under the influence of the
scarifications, the resolution of the inflammation is prompt and invariable, and
takes place almost always the day after the operation. After some time, there
will be observed small white lines — the cicatrices of the punctures. I know of
no objections to this practice, but the difficulty of getting at the seat of the disease,
or when the intensity of the inflammation prevents the opening of the jaws.
Boyer speaks strongly of scarifications in cynanche tonsillaris, but only as an
occasional operation. It is remarkable that he should not have recommended
them more generally, after using these words: “ by scarification the alarming
progress of the symptoms is arrested, and a prompt relief is given to the state of
anxiety under which the patient labours.” I scarify at the commencement of
the inflammation, or at its height, according to the time of my arrival.

I have also recourse to scarifications in laryngitis and pharyngitis, and always
with the greatest success. They are certainly more efficacious than cupping,
and avoid the marks in the neck. B. ^ F, Med. R^v. April, 1839; from Bulletin
de rjlcad. Roy, de Med. No. 1. 1838.

20. Use of Caustic Issues in Phthisis Pulmonalis. — M. Bricheteau has for
some years past been in the habit of using, with very decided advantage, caustic
issues, formed immediately below one or both clavicles, in cases of pulmonary
consumption; even when the disease is far advanced, and auscultation has indi-
cated the existence of tuberculous caverns in the lungs. That a powerful local
derivative, like an issue, may have a decided influence in arresting at least the
pirogress of morbid action, however serious, in an internal vise us, is well known
to every medical man; and that in many cases it has this effect on the softening
and ulceration of tuberculated lungs cannot, in M. Bricheteau^s opinion, be
gainsayed by any unprejudiced observer of his practice at the Hopital Necker.
Even where an absolute cure is not obtained, a great mitigation, and often a
marked retardation, of the disease follows the establishment of caustic issues
below the clavicles— provided always the rest of the treatment be at the same
time judicious and appropriate.

We shall very briefly mention the histories of two cases recently treated in
the hospital.

A young married woman was admitted in the following state on the 6th of
June, 1837.

She was distressed with cough, puriform expectoration, copious sweats, and
vomiting after the fits of coughing: there was a sharp stitchy pain felt over the
right side of the chest. On examining the chest with the stethoscope a distinct

461

Special Pathology and Special Therapeutics,

gurgling sound was audible beneath the right clavicle; the respiration was
cavernous behind; and these two symptoms became more marked, when the
patient coughed; there was considerable dulness on percussion beneath the right
clavicle. The patient was so weak that she could not walk about.

A large caustic issue was established immediately under the right clavicle,
and demulcent medicines and diet were prescribed.

This treatment was persevered in for six or seven weeks; and by that time
most of the unfavourable symptoms had disappeared, and the woman began to
recover her flesh and strength. Ultimately she did well.

Case 2. — A middle-aged woman had, after repeated attacks of hemoptysis,
become affected with all the usual symptoms of pulmonary consumption — cough,
copious puriform expectoration, night sweats, and diarrhoea. She was considered
by the physicians of La Charite hospital to be decidedly phthisical. Under the
use of a large caustic issue beneath the right clavicle, and appropriate attention
to the most troublesome existing symptoms, this woman regained her health so
well, that in the course of two months she was able to leave the hospital, and
soon after resumed her occupation of a washerwoman.

At a, subsequent period this woman was admitted fora syphilitic affection.
Her pulmonary symptoms had not returned. On auscultating the chest, the
respiratory murmur was found to be very feeble under the right clavicle, and
there was considerable dulness on percussion over that point. Posteriorly the
sounds indicated the adhesion of the pulmonary pleura to the ribs.— La Langette
Fran^aise,

21, Infiammation of the Umbilical Vein in Infants. — M. Osiander, Meckel, and
Sdsse were the first who described phlebitis of the umbilical cord. M. Duplay
has recently had an opportunity of examining several cases of it at the Hopital
des Enfans trouves at Paris; and the following is a brief abstract of his paper in
a late number of the U Experience.

In his first case, that of an infant which died on the fifth day after birth, puru-
lent matter was found in the umbilical vein from the navel to its entrance into
the liver; the small intestines exhibited here and there points of inflammation
and ulceration.

In the second case — neither the age, nor the symptoms present during life are
mentioned — the umbilical vein was found full of pus, and its parietes were some-
what thickened; the umbilical arteries also contained pus. Purulent matter
w’as found in both auditory passages, and likewise under the arachnoid mem-
brane. Both pleurae were coated with pseudo-membranous pellicles of recent
deposit.

Third Case. An infant died on the tenth day after birth, having been affected
from the fourth day with colicy pains, diarrhoea, vomiting, and meteorism of
the abdomen. The peritoneum was found on dissection to be inflamed and
partially coated with a membranous deposit, and there was a sero-purulent effu-
sion in the abdominal cavity. The branches of the vena portae, and especially
the umbilical vein, exhibited a preternatural turgescence; this was found to- be
owing not so much to congestion, as to a thickening of their parietes. The
trunk of the umbilical vein was a full line in the thickness of its walls, and its
branches were even more remarkably affected. The cavities of all these vessels
were coated internally with membranous deposit.

In the fourth case; the infant died on the seventh day after birth, after having
suffered from severe pain in the bowels, vomiting, icterus, &e.

On dissection, all the morbid changes characteristic of peritonitis, were dis-
covered; the umbilical vein and its branches were thickened, and lined with
purulent matter internally.

Case fifth. — An infant died on the third day after birth, in consequence of an
erysipelatous affection of the body.

The intestines and liver were found to be inflamed, coated with lymph, and
also with a puriform exsudation. The umbilical vein, from the navel to itf
insertion in the liver, was filled with yellow pus.

39*

462 Progress of the Medical Sciences.

In the sixth case, the infant was atfected with symptoms of icterus, purulent
ophthalmia, and an erysipelatous affection of the face, having a tendency to
gangrene here and there: it died on the tenth day after birth.

Along with certain morbid changes in other parts, the umbilical vein was
found to be filled with puriform matter, and to have its parietes considerably
thickened.

General JRemarhs. — Our knowledge of the history of phlebitis of the umbilical
cord is too imperfect to warrant us in speaking, with any certainty, on any of its
characters or features.

As to the cause of disease, M. Sasse and others have attributed it to the irrita-
tion arising from the ligature of the cord, and from the ungentle attempts, some-
times made, to squeeze the blood out from it.

The consequences or effects of the lesion seem to be usually peritonitis, icterus,
and rapid exhaustion of the vital energies. — Med. Chir. Rev. from U Experience.

22. Case of Laryngitis, complicated with Bronchocele, in which the external
application of Croton Oil was successfully employed. By A. Campbell, M. D. —
“ March 26, 18.34. A table-attendant, aged 19, strong and healthy, complains of
considerable pain in the region of the larynx, with a feeling of extreme tight-
ness, and incessant desire to cough. The voice is weak, unmodulated, and dis-
agreeably hoarse on attempting to speak; he finds it difficult to produce vocal
sounds, but, after expiring forcibly, the voice is elicited. There is no fever, or
quickening of the pulse. No pain in the thorax, nor are the bronchi affected.
Five days ago, he first observed the commencement of the above symptoms,
which have continued to increase until now, when he is nearly aphonic, and much
distressed by the constant necessity to cough. There is no pain or fever on firm
pressure of the larynx, nor is there any appearance of inflammation in the pha-
rynx; there exists a distinct enlargement of both thyroid glands; the swellings
are soft, elastic, and fleshy, each the size of a small apricot; has not previously
been affected with goitre, and was not aware of the presence of that disease
when he applied for relief. He attributes the laryngitis to exposure during the
night, as he was at the time of attack accustomed to sleep in the open air. The
following mixture was directed to be made, and rubbed on the throat for half an
hour twice a day: R — 01, Croton ^i.; 01. Olive ^ij. — M, The throat to be
covered with a flannel bandage.

March 28^A. — A crop of pustules have appeared on the neck; pain of larynx
diminished; hoarseness continues.

“The croton oil frictions to be continued.

April \st, — The external larynx raw and ulcerated; voice restored to its
natural tone; pain gone; goitre remains; discontinue medicine.

“ April 15/A. — Integuments of throat healed, and goitre completely disap-
peared.

“The efficacy of croton oil in removing laryngitis is too well known, I believe,
to require further corroboration; consequently, the interest of this case (if it has
any) consists in the manner in which the goitre was affected by the croton oil.
During the removal of the disease in the larynx, the goitre was apparently unaf-
fected; but, at the expiration of fifteen days from the cure of the laryngitis, and
from the suspension of medical treatment, the enlargement of the thyroid glands
entirely disappeared.

“ Should future trials with croton oil prove, that it is efficacious in removing
goitre, the result will be one of great importance .as the enormous expense of
iodine renders its general use (in countries where goitre prevails to a great
extent) quite out of the question.” — Transactions Med. Phys. Society, Calcutta,

vol. viii, part i.

23. Epidemic Scarlet Fever as it occurred in Edinburgh in 1835-36. Scarlet
Fever has been so frequently prevalent and so fatal a disease in this country, that
whatever is calculated to throw any light upon its nature or treatment has the
strongest claims to our attention. An abstract, therefore, of some of the accounts

463

Special Pathology and Special TherapeuticSo

of this disease as it occurred in Edinburgh in 1835-36 cannot but be acceptable
to our readers.* As we shall deem it of consequence, to dwell to a degree of
minuteness which some will consider tiresome, upon those facts which elucidate
the precise character and violence of the epidemic, it is best at once to state that
this course seems to us necessary for the appreciation of remedies, or of any
course of treatment. It is unquestionably the neglect of first determining these
points, which has given rise to so many errors and such contradictory state-
ments relative to the value of particular remedies and plans of treatment; and
which has often led practitioners to ascribe the small mortality occurring in their
practice to the measures pursued, when in fact, it was entirely due to the mild-
ness of the epidemic, or of the particular cases which fell under their treatment.

Some cases of Scarlet Fever occurred in Edinburgh in July, 1835, but it was
not until later in the year that it prevailed to any extent. Towards the end of
autumn, and still more during the winter and spring months, Mr. Wood states, in
an interesting paper in the Edinburgh Med. and Surg. Journ. (January, 1837,) “ it
was very generally diffused over the city and neighbourhood, raging in the form
of a very widely spread and severe epidemic; attacking, in its course, a great
many persons of all ranks and ages, and of both sexes, and j)roving fatal in a
great many instances. It is a remarkable circumstance that the fever extended
nearly as rapidly, proved as severe, and was as destructive of life, in the fami-
lies of the higher ranks, living in large houses, in open airy situations, as in
those of the lower, crowded together in small airless dwellings, in narrow
streets and lanes. Indeed, I have some reason to think, from accounts I have
received from my medical friends, that even a larger proportion of the sufferers
from the fever in the higher ranks have fallen a sacrifice to it, than in the lower
during this epidemic. The fever became less frequent as the summer advanced,
and assumed rather a milder character, but it has continued to prevail to a con-
siderable extent, both in the town and neighbourhood, down to the present time;
and it has lately proved fatal, and that very rapidly in some cases. During the
existence of the fever in Edinburgh, it has been met with in almost all the towns,
and in many parts of the country, both in Scotland and in England; and I am
told also in some parts of the continent of Europe, and of America.”

Below will be found abstracts of the accounts of the disease as it appeared in
some of the Charitable Institutions of Edinburgh.

24. Account of Scarlet Fever as it occurred in George Heriot's Hospital^ Edin~
burgh. By Wm. Wood, F. R- S. E. — Scarlet Fever appeared in this institution
early in January, 1836, and continued to prevail there till the month of March.
During the whole of this period, the weather was remarkably bad, there being
many great and sudden alternations of heat and cold; much rain, hail and snow,
following each other in rapid succession, and frequent gales of wind. It reap-
peared in November, and in December, there was one boy convalescent from an
attack.

This hospital contained when the epidemic made its appearance, 180 boys
from the age of 8 to 14; 17 female and 10 male adults, making a family of 207
individuals. There were in the hospital two rooms for the exclusive use of the
sick, lar’ge, well heated and ventilated, each capable of containing more than 12
boys in separate beds. There was a well constructed warm bath, in a small
room adjoining to and directly communicating with each of these sick wards;
and from an early period of the epidemic water was kept constantly boiling, so
that a bath of any required temperature could be had immediately when wanted.
There is also another room, capable of containing more than 6 boys in separate
beds, which was employed, in the first instance for the reception of the invalids
until the nature of their disease was satisfactorily ascertained; and it was after-
wards used lor the accommodation of the convalescents.

* S( m3 account of this epidemic has already been given in this Journal, (Feb., 1837,
p. £03, et seq.,) but further details will be interesting, inasmuch as the experience of
diffe:ent practitioners is far from being in accordance as to the treatment which proved
most suecessful. — Ed.

464

Progress of the Medical Sciences*

Upon the first appearance of the Fever in the hospital means were used to
arrest, if possible, its progress, but without success. It spread rapidly, and by
the end of a month, 31 of the boys had been attacked with it; in another month
5 more, and in addition to these cases, the house governor became aflected with
fever and sore throat, bearing all the characters of scarlatina although he had had
the disease when a boy, and the sick nurse suifered from a similar illness. W iih
tlie case which occurred in November, there were in all 45 well marked cases
of the fever.

“ The boys, in the early part of the year, came into the sick room very indis-
criminately from the five sleeping wards; but, on the whole, as was to be
expected, more of the younger, than of the older suffered from the disease. A
good many of the bed-fellows of those who took the fever remained free from
all complaint, although some of them had not been previously affected with it.
Of the seven boys who were taken ill towards the end of the year, four came
from the slee})ing ward for the younger boys, and all of them had been admitted
into the hospital in the month of June, after the fever had left it for a time. Inde-
pendently of the forty-five cases of fever above alluded to, several of the boys
and female servants of the institution suffered from a greater or less degree of
sore throat, with slight fever, but these were not reckoned cases of scarlatina, as
they did not exhibit any very characteristic marks of that fever; although it is
not improbable that, in some of them, the illness was a modification of the
disease, produced by exposure to contagion.

“ Of the forty-five persons who were considered to have passed through the
fever in a distinctly marked form on this occasion, thirty-eight were understood
not to have had it previously; five to have had it; and no information could be
procured with respect to the other two. One only of the boys who had been affected
with the disease in the hospital during the epidemic of 1832-33, took it in
that of 1835-36, although many of them were still inmates of the house; and it is
rather remarkable, that this boy was Daniel Mathieson, mentioned in my former
communication, as having been attacked during his convalescence from well-
marked Scarlatina anginosa, while still exposed to the contagion in the sick-
room, with a renewal of fever and sore throat, attended with a renewed eruption,
bearing all the characters of scarlet fever. He happened to be in the sick-room
with slight inflammatory sore throat, at the time when the first patient was
brought there with the fever in January,, 1836, was thus exposed to the con-
tagion, and returned to it in the course of about thirteen or fourteen days, labour-
ing under fever, eruption, and sore throat; but with him, on this occasion, the
disease was of a very mild nature.

“ The fever in the hospital has proved unfortunately to be a very severe one,
and four of the boys have fallen a sacrifice to it. In this, as indeed in all epi-
demics, even in those of the most malignant character, the disease has been
mild, in a considerable proportion of the cases, and attended with little or no
danger; in others, the symptoms have been alarming, occasionally from an early
stage of the complaint, and very little under the control of medical practice.”

No case was met with in the hospital during the epidemics of 1804, of 1832-33,
or of 1835-36, of that form of the disease in which there is fever with scarlet
eruption distinctly marked, but without any affection of the throat {S. simplex
Willan), and Mr. Wood thinks that the existence of true scarlatina without
some affection of the throat is a rare occurrence; and that upon careful inspection
this part will be generally found more or less inflamed.

Mr. Wood is disposed to believe, that an erroneous opinion may have been
formed as to the frequency of its occurrence from the state of the throat having
been overlooked, in consequence of being slight and attended with but little
pain. Mr. W. says he has frequently detected swelling and inflammation, and
occasionally also superficial ulceration of the throat, in persons, who on previous
inquiry, would not allow that they had either pain or uneasiness in it.

By far the greater number of cases were of that variety in which, along with
lever and eruption, there are more or less swelling and inflammation, and
frequently some degree of ulceration of the throat (/i>. anginosd) one or two of

special Pathology and Special Thefapeutics, 465

the cases might be referred to the variety termed S. maligna, but this last Mr. C.
considers as differing from the former merely in degree. In only one case was
there any degree and that a slight one, of the foul foetid sore of the throat, which
is generally an attendant on the fever in its most malignant form. In all thirty-
five of the patients may be classed under the heads of S. anginosa and maligna.
In ten, the fever was attended with sore throat, without eruption, {S, faucium,
Tweedie); in some of these the patient had never before had the disease, in others
they had been affected with it at a former time. “There is no reason to doubt,”
Mr. W. thinks “ that the affection in these last cases, is produced by exposure
to the contagion; that it seems to bear the same relation to scarlatina that
secondary does to primary small-pox; although it proves, occasionally, as severe
a complaint as in its original form and the same severity has been remarked in
some of those cases, in which the disease appears, for a second time in its per-
fect form, of fever, eruption and sore throat. I have not been able to satisfy
myself, whether persons affected tvfith this secondary form of scarlatina, are
capable of communicating to others that disease in all its varieties; but I am
rather disposed to think so; at all events, there seems no reason to doubt, that
they are capable of communicating that kind of sore throat which is generally
attended with white specks on the tonsils. Of the thirty-five cases of the fever,
belonging to the varieties denominated scarlatina anginosa and scarlatina maligna,
four were said to have been previously affected with the disease in one form or
another; and amongst them one of the boys in whom it proved fatal; thirty were
understood not to have previously suffered from it; and in regard to the other,
no information could be procured. Of the ten cases of scarlatina faucium, two
were believed to have been previously affected with it; seven not, and in one it
•was a matter of doubt. One of the boys, who was attacked with fever, sore
throat, and eruption, on the 21st of January, and was reported to be conva-
lescent on the 2d of February, though still confined to the convalescent room,
had a renewed attack of sore throat and fever, preceded by cold shivering, on
the 9th of that month. There was much redness and swelling of the tonsils,
and one of the submaxillary glands was much enlarged; but there was no erup-
tion. The symptoms of the fever have been, with a few exceptions, the same
with those detailed in my former communication; but have been met with in
different degrees of severity, and in varied combinations, in the different epi-
demics, and individuals. In general, the fever in the hospital, in 1836, has had
much more of a typhoid type than in 1832-33; the first stage has been more
distinctly marked, and of longer duration; there has been much depression of
spirits, with languor, lassitude, and great general uneasiness; total loss of appe-
tite, and nausea, attended occasionally with frequent vomiting; in one of the
cases there was early in the disease some degree of diarrhoea; but this was not a
common symptom.

“In the first stage there have been often also regular fits of cold shivering, the
head ache, and the pulse has been frequent, but languid. Sometimes there
has been, from the first appearance of the symptoms, a degree of swelling and
redness of the throat, with white specks on the tonsils. The vomiting has been
frequently continued in the second stage, and in it the pulse has become much
quickened, but languid, it has been very seldom under 120 beats in a minute,
and often very considerably above that. The eruption, in the cases in which it
has been present, has come out rather slowly, and partially over the body at
first, and has been, in general, of a less bright-red colour than during the former
epidemic. The rash in one of the boys, who died with strongly marked typhoid
fever, assumed an appearance which I have always found to indicate a very
dangerous state of the disease; it was of rather a pale-red colour on most parts
of the body; but there were many large patches of the skin of a purplish or
claret colour; and the fingers, wrists, and lower parts of the fore-arm, as well
as the toes, feet and ankles, were tinted of the same colour, giving to the
extremities very much the appearance of their having been immersed in a light"
coloured infusion of logwood. At the same time, the fingers and toes were
swelled; but this was a different affection from the rheumatic swellings which

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have been frequently met with during the present epidemic, and from the oede-
matous swellings, so common as sequelae of the fever. In the boy who was
first taken ill, there appeared, on the second day of the disease, along with the
general rash, which was at first of a pale-red colour, and only partially diffused,
a number of small elevated red papulae, giving an appearance to the skin very
like that which is sometimes mef with in the early stages of small-pox. when
there occurs along with the pustular eruption, a ruseolous rash. The general
appearance, indeed, was so similar in this case, that it led to some doubt for a
day in regard to the real nature of the disease. The heat of the surface of the
body, after the reaction, has been generally less than is usual during scarlatina;
and there has been a tendency to cold shivering, produced by any part of the
surface of the body being exposed to the air. The sleep has been confused,
and there has been often delirium, the approach of which was marked, in
one or two of the boys, by a peculiar quickness in their movements, and the
unnatural rapidity with which they answered questions put to them. In one of
the fatal cases the delirium was of a violent kind, and the patient was disposed,
not only to leave his bed, but also to strike the friends who were in attendance on
him. The breathing has been generally quick, and attended, in some of the
severe cases, with frequent short sighs. In all the patients the throat has been
more or less affected. The inflammation has been generally of a dark-red colour,
with white specks; and it has sometimes extended downwards along the pha-
rynx, and even in all probability affected the oesophagus, and upwards to the
roof of the mouth, into the cavities of the nose, and also into the ear by the
Eustachian tube. In many cases there has been ulceration of the tonsils, more
or less deep; but in none has there been any extensive sloughing. A quantity
of tough dirty-white mucus has been generally accumulated on the back part of
the fauces, and in the neighbourhood of the glottis, producing much painful irri-
tation, and troublesome short cough. The tongue has been commonly moist,
and loaded, with red papillae projecting through a brownish-yellow crust, and it
has been red and tender along its margins; sometimes it has been of a dark-red
or purplish colour, but clean, occasionally glossy; and in some cases, towards
the end of the fever, it has become superficially ulcerated. The mucous mem-
brane lining the nose and eyelids was inflamed in one or two of the cases, and
discharged an acrid fluid, w'hich produced ulceration of the lips and surrounding
parts. Some of the cervical glands were generally more or less enlarged, and
painful to the touch. The recovery of the invalids has been commonly slow.
In some cases in the course of the present epidemic, as in that of 1804 and 1832,
the pulse has been found, for many successive days, during the period of con-
valescence, considerably slower than natural, w hen the patients seemed in all
respects well. This happened at a time when they w'ere still confined to bed,
and were living almost entirely on milk and vegetable food.

Such have been the symptoms of the fever in the hospital during the present
epidemic, and these have been met with in very different degrees of severity,
and in various combinations, in the different cases. Four of the forty-five
patients have died; three of them from the primary and direct effects of the fever,
and one from its indirect and secondary consequences. 1 shall afterwards give a
full account of these cases; but I may here mention, that one of the boys died
unexpectedly, in little more than forty-eight hours from the first attack, without
the occurrence of any symptoms of malignancy, or indication of danger, or with-
out any appearances having been discovered on dissection to explain the cause
of death. Another expired in little more than thirty-six hours, in exactly simi-
lar circumstances. In both these cases the symptoms were those of scarlatina
anginosa, and a state of collapse took place very soon after the disease com-
menced. In a third, the fever lasted till the seventh day, when the boy sunk,
after having suffered from all the symptoms of the disease, in its most malig-
nant form, wdth the exception of there having been no very severe or serious
affection of the throat. The fever partook in him, very strongly, of the typhoid
type; the general eruption was rather pale, and there were large patches of the
skin of a light claret colour; the extremities had a uniform tint of the same

467

Special Pathology and Special Therapeutics.

colour, and the fing’ers and toes were swelled. There was much delirium,
occasionally of a violent nature, and requiring the use of a strait jacket; the eyes
were red. In the fourth fatal case, the symptoms were those of severe scarla-
Una anginosa^ for although there wa^ much fever, with great restlessness, gene-
ral uneasiness and delirium, there was not that appearance of the eruption and
of the throat which is generally supposed to mark the scarlatina maligna. The
boy was ill for thirty-three days, during which he was occasionally better and
worse, and his death seemed to be caused by a diseased state of the bronchial
and mesenteric glands, with probably some organic derangement of the parts in
the vicinity of the glottis, as we were led to suppose, from the nature of the
cough, which was a very painful and distressing symptom; but we had no
opportunity of ascertaining the accuracy or inaccuracy of this opinion, as leave
to inspect the body was refused by the friends.

“ The principal indirect ox secondary affections^ produced by the fever, have been
dropsical effusions in various parts of the body, and rheumatic affections of the
joints^ which have been unusually frequent during the present epidemic. There
has been no suppuration of the external glands in any of the patients, and of the
ear in one only; and it was a very slight affection, and gave little trouble.

“ In eight of the forty-five cases, more or less oedema has been observed; in five
of them, it was unattended with any disagreeable effects; but in three, there
were severe and strongly marked symptoms of affection of the head and chest.
In none of the eight cases has the fever been very severe in its primary stages;
in most of them it has been mild, and in all there has been a distinctly marked
eruption. In none of the seven boys who were affected with the fever in the
months of November and December was it followed by dropsical effusions.
The oedema appeared some time after the fever had subsided, and while the
patients were considered to be convalescent. It has been occasionally observed
in the face alone, and when it affected the hands and feet, as was the case in one
of the patients, it began in the face, took place next in the hands, and then in
the feet. The average period from the commencement of the disease, at which
the dropsical symptoms came on, in the eight cases, was nineteen days, the
earliest being seventeen, and the latest twenty-two; and, in this respect, there is
a remarkable coincidence with what was observed in the nine boys who suf-
fered from the same affection in the hospital in 1832-.33.*

“ In all the dropsical cases, the urine was coagulable, to a greater or less
extent, by the application of heat, and it was of a less specific gravity than
usual. This was satisfactorily ascertained by many trials made by my friend
Professor Christison, who took an anxious interest in the investigation. The
coagulable urine was unnatural in colour, occasionally resembling whey, and
its appearance was generally so peculiar, that it was easy to prognosticate, from
that alone, whether it would or would not be found to be coagulable. In some
of the patients, it was of a red colour, from a mixture of blood, very much
resembling water in which meat had been washed; and it went through various
shades of red and brown, before it assumed a healthy appearance. During the
presence of oedema, the urine v;as small in quantity, and in one case, the secre-
tion seemed to be nearly suspended for a short time. The diminished specific
gravity and coagulability of the urine remained in one of the boys for a consider-
able time after the dropsical symptoms had disappeared, when he seemed to be
totally free from disease, and was engaged in his usual avocations. In some
cases the oedema was evidently caused by imprudent exposure to cold; and more
particularly to a current of cold air, during the period of convalescence. In one,
it was brought on by a window of the convalescent room having been opened,
for a very short time, by one of the boys, for the purpose of speaking to a com-

* “ Its first appearance,” according to Dr. Wells, “ is generally on the twenty second
or twenty -third day after the commencement of the preceding fever:” and he adds, “ it

may come on as early as the sixteenth day and its attack may be delayed to the

twenty-fifth.” — Transactions of a Society for the Improvement of Medical and Chi-
rurgical Knowledge, Vol. iii. p. 168.

46S

Progress of the Medical Sciences*

panion on the outside of the house. In other instances, however, it came on
before the patients had been allowed to leave their beds; and when the most
unremitting attention had been paid by the nurses to prevent any improper
exposure. The dropsical affections had all the characters of that disease in its
acute form; the swellings w*ere more elastic to the touch, and pitted much less
on pressure than in cases where they arise from debility, and are the effects of
organic derangement of the internal viscera. In the five patients, in whom there
were no unpleasant symptoms connected with the dropsical swellings, these
were observed in the face alone. In two, in whom there were symptoms of
affection of internal parts, they were also confined to the face; but in the third,
they appeared in the face, hands, and feet in succession. The symptoms of
affection of the head and chest were very similar to those produced by effusion
of serum or other fluids into these cavities; but it is difficult to suppose, that any
considerable quantity of fluid had actually been effused into them, considering
the great rapidity with which the symptoms were removed by general blood-
letting and other powerful remedies. Sometimes previously to the appearance
of the oedema, the pulse was observed to be slower than natural, and continued
so for a time; but in all the cases in which symptoms indicating an affection of
the head and chest were connected with the cedematous state, there was more or
less general febrile excitement, and the pulse was occasionally remarkably fre-
quent; with the heart beating tumultuously; the symptoms seldom came on till
several days after the oedema had appeared, and then, sometimes, very sud-
denly, and with great violence.* 1 am happy to say, that none of the patients
in the hospital have died of this affection during the present epidemic, though
several of them have been in considerable danger, and have required active treat-
ment for the removal of their complaints. A great difference of opinion has
existed among writers on scarlatina, in regard to the degree of importance to
be attached to these dropsical affections; by some they are considered to be of
very little consequence, while, by others, they are said to be attended with even
more danger than the fever itself in its primary stages. This difference of opin-
ion seems to me to have arisen from the different nature of different epidemics,
and from the different modes of treatment which have been employed; particu-
larly for the removal of the dropsical affections. The comparative degree of
danger from the primary fever and its secondary effects in different epidemics,
is well illustrated by the histories of the disease, as it appeared in Heriot’s Hos-
pitalin 1804, 1832, and 1836. In the epidemics of 1804 and 1832-33, none of
the patients died of its 'primary effects^ while in that of the first, three; and of
the second, one died of the dropsical affections. In the epidemic of 1836, three
died of its immediate effects, and one of the more remote; but none with dropsical
symptoms.

“At all events, the period during which cedematous swellings are present,
should invariably be considered as one of danger, requiring the most watchful
care of the medical attendant, as alarming symptoms frequently appear very
suddenly; for the removal of which, the most active treatment is essentially
required, and without loss of time; and, fortunately, in no stage of the disease
are powerful remedies more decidedly useful. The cases in which symptoms
were produced by the dropsical affections, or, perhaps, I should rather say, by
the state of the constitution giving rise to them, seem to me to be of sufficient
importance to be given in detail; in the meantime I may state, that one of the
boys, in whom an cedematous swelling of the face was observed on the 20th day
from the commencement of the fever, complained suddenly, on the 25th day, of
very violent pain in the forehead; he was at the same moment totally deprived
of his eye-sight, and the pupils of the eyes became very much dilated. His
urine had been previously of a dark red colour, and coagulable; and his pulse
had been for a few days rather below the natural standard, but he had not com-
plained of any thing. After a few minutes the pain of the head went suddenly

* On this subject Dr. Wells says, “ Symptoms of extreme danger sometimes appear
as early as the third day after the face has begun to swell.” — (Loco citato.')

469

Special Pathology and Special Therapeutics.

off, and his vision was immediately restored. I was informed by one of my
sons, who happened to be in the sickroom at the time of this singular affection,
that, just before he recovered his sight, the iris of both eyes was, for a short
time, in a state of rapid dilatation and contraction. Blood, which was imme-
diately taken from the arm, was much cupped, and had a thick buffy coat; an
additional quantity drawn some hours afterwards was of natural appearance.
This patient made a perfect recovery without any other severe symptoms having
taken place.

“ In another of the boys, slight oedema of the face appeared on the 20th day
of the fever, while he was still confined to bed. On the 25th, there was some
oedema also of the hands, and the pulse was 100. Medicines were given for
the removal of these symptoms, and on the morning of the 27th day, the swel-
ling of the hand was reported to have disappeared; that of the face to be much
lessened, and the pulse was 94. Soofi after this report had been made, he had
a severe and long-continued fit of cold shivering, \vhich was removed by the
warm bath; but immediately afterwards he became extremely hot, and his face
was much flushed. He vomited, and complained of great pain in his head; the
breathing was quick, short, and oppressed, and the heart beat tumultuously; the
pulse was too rapid to be easily counted. These unpleasant symptoms were
considerably relieved by blood being drawn freely from the arm, and by pur-
gative medicines. In the evening, however, he was still hot and feverish, and
the breathing w^as quick and oppressed. He was again bled with great relief,
and next day he was in all respects better; he had slept well; looked comfort-
able; his breathing was much more natural, and his pulse was less frequent.
After some time his feet swelled considerably; he was plagued with a trouble-
some cough, and became affected with severe rheumatic pains in his joints; but
he recovered perfectly, though slowly.

“ Four of the boys who had the fever early in the year, and Mrs. Stewart,
the nurse, suffered from painful rheumatic affections^ principally of the smaller
joints, as sequelae of the fever. None of the patients who were taken ill in
November and December had any attack of this sequela. Mrs. Stewart, who
had laboured under scarlatina faucium,, was attacked during her convalescence
with long-continued and very painful lumbago. The four boys had been
affected with scarlatina a7iginosa, and two of them in a very severe form; in
these two, there were rheumatic pains of the extremities generally, without any
appearance of swelling or of external inflammation, in one of them they com-
menced on the third, and in the other on the fifth day of the fever, in both dur-
ing the presence of the eruption. In the third boy, the ankles were affected,
and although there was neither swelling nor inflammation of them, the pain was
much increased on their being touched, or on motion; this affection came on
very late in the disease, and after dropsical symptoms, which had been both
troublesome and tedious, had been removed. In the fifth case, the rheumatic
affection assumed rather a remarkable character; the boy complained, on the
seventh day after being attacked with the fever in the form of scarlatina anginosa^
during the existence of desquamation of the skin, of very severe pains in the
legs and arms; on the eleventh day there was much painful swelling of the
fingers; on the twenty-second, oedema of the face appeared, with pain in the
head; on the twenty-ninth, there was a renewal of the pain in the head, and
there were symptoms of affection of the chest, both of which were removed by
blood-letting and other remedies; on the thirty-eighth there was much pain in
the hands, and in both hams, so much, indeed, as to prevent him moving easily
in bed, and much increased by the slightest touch of the parts affected, which
were a little swelled, but not red. On the fortieth day he complained of tooth-
ache, and severe rheumatic pain over the right eyebrow. On the fifty-third
day, there was a great deal of pain in the left ankle and knee, which was much
swelled. After the decline of these symptoms by the use of leeches, sinapisms,
and blisters, he complained of great pain in the upper and fore part of the left thigh,
and the slightest touch was insufferable; he was for a long time confined to bed.
For some time after the pain had so far subsided as to allow of his being taken up,
No. XLVIII. — August, 1839. 40

470

Progress of the Medical Sciences.

he was unable to make any use of the left leg in walking, partly from pain, but
principall)^ from a want of power and command of the limb. He could not rest
any weight upon it, and when it was moved, it shook in a singular way; alto-
gether, the mode in which the limb was used was very similar to that produced
by paralysis. This affection remained for many months, although he was in
the enjoyment of good general health, and it went off slowly and gradually,
during a residence at the sea side, and the use of sea bathing. He is at present
in good health, and has regained the perfect use of his limbs.

“ Two of the boys who had been affected with Scarlatina anginosa in rather
a mild form, suffered from an attack of pneumonia after their recovery. One of
them, who had had some degree of cedema of the face without any unpleasant
symptoms, was attacked with pneumonia eleven days after he had returned to
his own sleeping ward, and been engaged in his usual avocations, and above
seven weeks from the commencement of the fever. In the other, the inflamma-
tion of the lungs took place above a month from his having left the convalescent
room, and above two months from the first symptoms of the fever.

“It is a very remarkable circumstance, and one not easily accounted for, that a
boy was attacked 29th February with small-pox while in the convalescent room, to
which, and to the sick-room, he had been confined for above a month, in conse-
quence of having been affected with scarlatina fauciumP * * *

“ On the 22d March, another boy; on the 31st a third, and on the 18th April,
two or more were attacked with modified small-pox; the last of these only had
been affected with scarlet fever. In all of them the disease was of a very slight
nature. In none of the patients, during the prevalence of the present epidemic,
has there been any erysipelatous affection, as had been the case during the former.

“The treatment of the fever in the hospital, during the present epidemic, has
been conducted on the same general principles as during the former. There
has been no disinclination on the part of Dr. Abercrombie, and myself, to em-
ploy general blooddetting, during the primary stages; wherever its use seems
to be indicated by great febrile excitement; or by the occurrence of symptoms
marking some local affection: but, on the other hand, we have not been disposed
to have recourse to it, as a general remedy, from any belief of scarlet fever, par-
taking always, or most frequently, so much of an inflammatory nature, as to
render its employment necessary, without some special indication. In conse-
quence of the sudden death of two of the boys, in a state of collapse, soon after
the fever appeared in the hospital, and of the disease having assumed much of
the typhoid type, we considered it improper, and unnecessary to use the lancet,
in the primary stages of the fever, in any but the first case which occurred.
Local bleeding by leeches has been frequently employed for the removal of
local symptoms. Emetics have been very little used, in consequence of the
languor, lassitude, and general depression of the patient, in the commencement
of the disease. Purgative and laxative medicines have been given freely, and
frequently, in all its stages. The tartrate of antimony has been much less em-
ployed, with the view of producing nausea, than on the former occasion; be-
cause the febrile excitement has been less; it has been frequently given, how-
ever, as a diaphoretic, in combination with other medicines of the same class.
Sponging with cold water has not been at all used; and with tepid, only in
particular cases, and in them cautiously, in consequence of the heat of surface
of the patients having been, in general, little above the natural standard, and of
there having been a tendency to cold shivering, produced by exposure of the
body to the air.

“ The warm bath has been very frequently employed, in all stages of the dis-
ease, and with the best effects. It shortened the duration of the cold stage, and
hastened the appearance of the eruption; in the febrile state, it allayed febrile
excitement, and tended to produce sleep; and, during the period of desquama-
tion, it relieved the unpleasant irritation produced by the affection of the skin,
and assisted in restoring it to a healthy state. The temperature of the bath was
regulated by the heat of surface of the patient. I am disposed to think, that
sufficient importance has not been attached to the w^’arm bath, as a remedial
measure, in scarlatina; and that it has not been hitherto used so generally, nor

471

Special Pathology and Special Therapeutics,

repeated so frequently, as it ought to be. I hope it will not be inferred, from
this statement in favour of the warm and tepid bath, in certain states of the
fever, that I arn disposed to undervalue the practice of sponging the surface of
the body with cold, or with tepid water; a pra.itice from w^hich the most bene-
ficial results have been obtained, under judicious manageraeni; but this practice
has not seemed a desirable one, as a general remedy, during the present epi-
demic, from the want of a high temperature of the surface of the body. In all
instances, where the patients could be placed in the bath, without much disturb-
ance, it was extremely pleasant to their feelings, and it was often asked to be
repeated.

“ Tincture of opium, in combination with antimonial wine, has sometimes been
given, during the state of desquamation, after the febrile state has subsided,
with a view of relieving the uneasy irritation produced by the state of the skin,
which is frequently so distressing as to deprive the patient of sleep.

“ In the management of the local affection of the throat, leeches have occasion-
ally been applied, where there was much inflammatory swelling of the tonsils,
and where any of the external glands were enlarged, and painful. Blisters have
been occasionally used in swellings of the submaxillary or cervical glands, after
the decline of the fever; but not often, during the febrile state, as they add to
the discomfort of the patient, and do not seem to produce much effect in lessen*
ing the internal affection of the throat. Infusion of roses, acidulated with the
sulphuric or nitric acid, and occasionally with an admixture of the tincture of
capsicum, has been much used as a gargle. In many cases, where there was a
great disinclination, on the part of the boys, to the use of gargles, they were
persuaded, as a substitute, to sip frequently leaspoonfuls of common syrup,
made pleasantly acid by addition of diluted nitrous acid. The strength of this
mixture was varied according to circumstances: in some cases it produced con-
siderable pain in being swallowed, by a person affected with sore throat, when
it hardly tasted acid to one without such affection. In all cases where there
was an accumulation of mucus in the mouth and throat, it was removed, as much
as possible, with a sponge, and by frequent washing- with tepid milk and water.
Upon the whole, I am disposed to think, that too much importance has occa-
sionally been attached in scarlet fever, to the .state of the throat, and to the
applications made to it. No doubt, in some cases, where there has been exten-
sive sloughing of the throat, and neighbouring parts, death has been caused by
the local affection; but more generally, I believe, the death is to be ascribed to
the kind and degree of the general fever, by which the state of the throat is
regulated, and consequently, the cure of the local affection must depend, in a
great measure, on the treatment of the fever itself.

“ Wine and other cordials were considered necessary in only a few cases; and
in them they were given with great caution. When wine was used, it was given,
at first, at least, diluted with water, and only in tablespoonfuls at a time, till
its effects, which were very carefully watched, were ascertained; and by these
its future use was regulated. Not more than six or seven of the patients in all,
had any wine or other cordial given to them in any stages of the fever, or during
their convalescence.

“ A strictly antiphlogistic regimen was followed during the whole period of
the febrile state, and for some time afterwards, and even when food of a more
nourishing kind was allowed during the convalescence, it was given sparingly
and cautiously, from a fear of febrile excitement being produced, not unlikely to
terminate in dropsical affections. And for the same reason, the greatest care
was taken to prevent the patients from being exposed to cold air for many
weeks after the fever had subsided.

“ In the treatment of the dropsical affections which followed the fever, the
remedies have been varied according to the extent of the tedema, and the nature
of the symptoms with which it was accompanied. In the cases where the
oedema was partial, and confined to the face, without any fever, or symptoms
of affection of internal parts, active purgative medicines were given, followed
by diuretics, of which digitalis was the one principally trusted to, on account of
its effect in lessening the force of the circulation; and the warm bath was

472

Progress of the Medical Sciences.

employed, with a strictly antiphlogistic regimen. Under this treatment, the
cederna generally disappeared, without producing any unpleasant effect. In all
cases, however, where, along with oBdematous effusion, there was febrile excite-
ment, and more particularly where symptoms appeared indicative of an affection
of any of the internal parts, and in our patients those of the head and chest were
alone affected, general blood-letting was immediately had recourse to, and
repeated at short intervals till relief was obtained. The rapidity with which
symptoms the most severe, and of the most alarming kind, disappeared under
this remedy was very remarkable. In no case, during the present epidemic,
have convulsion fits occurred either in the primary or secondary stages, as was
the case in several instances during the last. It is satisfactory to know that
recovery often takes place, under the use of blood-letting, of patients who have
been affected with very severe convulsive fits. Along with'^blood-letting, active
purgatives have been employed. The warm bath has been repeated frequently,
and diuretic medicines, and occasionally tartrate of antimony, have been admin-
istered.

“ Nothing seems to be better established, in the history of scarlatina, than the
fact, that the dropsical affections which so frequently follow it, are, in all cases,
more or less of the acute species, requiring, in many instances, the most power-
ful antiphlogistic remedies for their removal; and no greater improvement has
been made in the treatment of the fever and its consequences, than that of the
early and free use of the lancet in the dropsical affections. For this change we
are in a great measure indebted to Drs. Abercrombie, Bright, Christison, and
other medical men of the present times, who have thrown much light, in their
W'ritings, on the nature and cure of acute dropsies in general, and of the dropsical
affections occurring as sequelae of scarlatina in particular. But it ought to be
mentioned, injustice to Dr. Wells of London, that he, after stating as a specu-
lative opinion, that in this affection “inflammation maybe supposed to exist
sometimes in the head and the chest,” adds, “ and consequently bleeding, where
danger is urgent, may be employed with advantage.” In what follows, we
have a very striking instance of the strength of the prejudice which at that time
prevailed, against bleeding in these affections, from the dread of debility. “ I
must add, however,” he continues, “ that I have never prescribed bleeding
myself in this disease, and that possibly I should not have courage to prescribe
it, if a case were to occur to me, in which I might think it proper.” He farther
says, “ Whatever opinion may be formed of what I have just said, it seems very
evident that the dropsy, which occurs after scarlet fever, is in the beginning a
symptom of some state of the body different from debility. The dropsical
state, as it has appeared in Heriot’s Hospital during the present epidemic, seems
to have been more directly under the control of remedies, than the severe symp-
toms of the fever in its primary stages.

“ The rheumatic affections have been treated by the warm bath and warm
fomentations, and by the use of opium, combined with preparations of antimony,
or with ipecacuanha. Where there were swellings of the joints, leeches were
applied, and sinapisms, and blisters; and friction, with stimulating embroca-
tions, was afterwards had recourse to. In one boy, as formerly mentioned, after
the swelling and pain had been removed by these means, the power of the limb
was restored by sea-bathing, and a residence at the sea side of some months
duration.

“ On comparing the state of the fever in the hospital during the three epidemics
mentioned in this and my former communication, it appears that in 1804, of
140 inmates of the institution, fifty of the boys were attacked with the disease;
in all of them it was very mild in its primary stages^ and none died of its pri-
mary and direct effects. An emetic was given occasionally, but not generally,
on the approach of the fever, and towards its decline a moderate quantity of

* These observations are contained in a very interesting paper on the subject of
“ the Dropsy which succeeds Scarlet Fever,” by Dr. Wells, in the third volume of the
Transactions of the Society for the Improvement of Medical and Surgical Knowledge,
p. 167.

473

Special Pathology and Special Therapeutics,

wine was allowed. This seemed to be necessary in a few cases; but to avoid
th« appearance of partiality, the practice of giving it was general.”* * * § The treat-
ment consisted principally, however, in the use of purgative medicines, which
were given fully and freely in all stages of the complaint. The warm bath was
repeatedly used; and saline and diaphoretic mixtures were employed in a few
cases, with the occasional use of “ gargles, composed of port wine, diluted with
water, or of vinegar and water, sweetened with honey or sugar.”

Dr. Hamilton does not state the exact number of patients who became affected
with dropsical effusions; but three boys died, and two others were in great dan-
ger from their effects. In the fatal cases the patients died, he says, “ within
less than thirty-six hours from the recurrence of complaint, labouring under
symptoms denoting ascites, hydrothorax, and hydrocephalus. ”f The affection
was treated by the use of “suitable cordials, and purgative medicines of appro-
priate quality. ”i|: “ Strong purgatives were given in large and repeated doses,

sometimes twice and thrice, in the same day, before the necessary evacuation
was procured.” Stimulating glysters were also occasionally employed “to
support and promote the efficacy of the purgatives, and to insure a determination
downwards.” Blood- letting does not appear to have formed any part of the
treatment; but this is not to be wondered at, as at that time dropsical affections
were generally, or I should rather say universally, believed, by the medical
men of this country, to be in all cases the effects of debility. 1 have little doubt
that more of the fever patients would have been attacked with dropsy, and a
greater proportion of those who were affected with it, would have died, if it had
not been for the full and free way in which active purgative medicines were
given by Dr. Hamilton, in all stages of the disease, in opposition to the then
prevailing prejudice against their use, founded on the erroneous fear of their
producing injurious debility, and increasing the tendency to putridity. In this
mode of treatment of scarlatina, there was a near approximation to that of the
present day, in which even the more powerful antiphlogistic remedies, general
and local blood-letting, are had recourse to, under particular circumstances, with
the best possible effect in all stages of the disease. The prejudice against the
use of purgatives in scarlatina prevailed to a great degree for some years after
1804. Dr. VVillan, after giving an opinion against the use of blood-letting in
the primary stages of the disease, says, “ Purgatives have nearly the same
debilitating effect as blood-letting. They are indeed seldom necessary; for
though a few patients may, on the first day, be affected with bilious vomiting
and diarrhcea, the state of the bowels is more uniform than in other febrile com-
plaints.”§ It is rather remarkable, that no mention is made by Dr. Hamilton
of the employment of diuretics. This may have arisen, perhaps, from the great
confidence placed by the Doctor in purgative medicines, and in the effects of
calomel, which he gave very freely on this occasion, even to the extent of pro-
ducing a considerable degree of ptyalism.|l

“In 1832-33, of 206 inmates of the hospital, forty- four of the boys, and one
female adult took the fever. In most of these cases it was of a mild nature in
the primary stages, and none died of its primary and direct effects. Emetics were
occasionally given in the commencement of the fever; purgative medicines in all
its stages; the tartrate of antimony was often employed in nauseating doses to
lessen febrile excitement. Local and general blood-letting were had recourse
to in some few cases; sponging with cold, but more frequently with tepid water,
was much used, and also the w'arm bath. Stimulating gargles of various kinds
were employed. Wine was given in a very few cases.

“ On the whole, the facts observed lead to the inference that the febrile excite-
ment seems to have been greater during this epidemic than the former. Of

* Observations on the Utility and Administration of Purgative Medicines, by James

Hamilton, M. D. p. 196.

t Ibid. p. 194. t Ibid. p. 193.

§ On Cutaneous Diseases, by Robert Willan, M. D. p. 393.

II Hamilton, p. 195.

40^

474

Progress of the Medical Sciences.

the forty-five persons who had the fever, nine boys became affected with drop-
sical effusions; of these one died of hydrocephalus^ and several were in consider-
able danger, some of them having laboured under convulsions and symptoms
indicative of diseased action within the head, and others under symptoms of an
affection of the viscera of the chest. The treatment of the dropsical affections
consisted in the employment of general and local blood-letting, of strong purga-
tive medicines, and of diuretics, particularly digitalis, with the frequent use of
the warm bath, and occasionally of tartrate of antimony in nauseating doses.

“ In 1836, of 207 inmates of the house, forty-three of the boys, and one male
and one female adult took the fever. Of these cases, two boys died within
forty-eight hours of the attack, and one in seven days, all of them from its direct
and primary effects^ and a fourth in thirty-three days from its secondary conse-
quences, viz., affections of the larynx and of the bronchial and mesenteric glands.
The fever, which had much more of a typhoid type than during the other two
epidemics, was treated principally by purgative medicines and diaphoretics; in
some cases by wine and cordials, and by the frequent use of the warm bath.
Eight of the boys became affected with dropsical swellings, and symptoms indi-
cating internal affections of the head and chest, from the effects of which seve-
ral were alarmingly ill, but none died. This sequela was treated by free blood-
letting, general and local; by powerful purgatives, and by strong diuretics, with
the warm bath. Five of the patients, four boys and a female adult, suffered
from rheumatic affections^"' — Edinburgh Med. and Surg. Journ. January, 1839.

25. Extent of Prevalence and Mortality of the Epidemic Scarlet Fever in some of
the Public Institutions of Edinburgh. By Wm. Wood, F. R. S. E.

Year.

1804

1832-33

1835-36

“ The number of the inmates of the Trades’ Hospital, who suffered from the
* From dropsical affections.

t Three from primary fever, one from diseased mesenteric and bronchial glands,
t From primary fever.

Hospital.

Heriot’s,

Merch. Maid.
Trades’ Maid.

J. Watson’s,
G. Watson’s,

Orphan,

Total.

Inmates.

140

206

207

104

132

95 <{

120 Boys,

20 Adults, male
and female.

179 Boys,

10 Male adults,
17 Fe.male do.

180 Boys,

10 Male adults,

17 Female do.
93 Girls,

11 Fern, adults.
47 Girls,

6 Fern, adults,
64 Boys,

50 Girls,

18 Adults.

76 Boys,

5 Male adults,
10 Female do,

4 Children.

40 Boys,

40 Girls,

2 Male adults,
9 Female do.

1028

Cases of Fever.

50 Boys.

45 S 44 Boys,

^ 1 Fom. adult.

43 Boys,

45 1 Male adult.

Female do.

21 Girls.

7 Girls.

) 12 Boys,

) 10 Girls.

22'»

Boys,

Child.

adult

Deaths.

Kate or
Mortality.

1 Boy.^

1 to 16.66
1 to 45

4Boys.t 1 to 11.25

1 Boy.*
1 Boy.t

None.

1 to 22

1 to 16

I to 22.9

475

Special Pathology and Special Therapeutics.

fever, was, in all probability, materially affected by the breaking up of the esta-
blishment soon after its appearance there.” — Ibid.

26. On the Treatment of Scarlatina Anginosa. By Dr. Hamilton of Falkirk. —
“ I would remark, in the outset, that, in this disease, averages seem to me an
exceedingly fallacious mode of estimating the rate of mortality attending diffe-
rent kinds of treatment, when these are applied to different epidemics, or even
to those prevailing in adjacent localities. There can be little doubt, 1 think,
that the type, in the circumstances above stated, varies so much as to render
doubtful or to invalidate any conclusions that may be drawn from them. For
example, the volatile alkali in the hands of Dr. Peart, and the capsicum gargle
in those of Dr. Stephens, appear to have been considered as almost specific.
Other observers, in other epidemics, however, have come to widely different
conclusions. To the same effect, in the epidemic which prevailed in Edinburgh
during the latter part of 1833, and the commencement of 1834, it was a common
observation, that the cases occurring in certain localities, such as the Westport,
Grassmarket, Cowgate, Pleasance, &c. were much more virulent in their type
than those occurring in the New Town, or even than those which occurred in
Heriot’s Hospital, lying quite in the vicinity of the situations I have men-
tioned. It seems to me, therefore, that accounts of epidemics, or of modes of
treatment, which do not furnish us with an exact detail of at least the leading
symptoms of the cases, do not place before us the requisite data for drawing
accurate conclusions.

“ But if this be true, in regard to scarlatina as a whole. I believe it to be espe-
cially so when speaking of the state of the tonsillar inflammation; and I hold
this opinion for two reasons; because the mere vague statement of “ The
throat being much inflamed,” or similar gev^ral expressions, give us no avail-
able information, as this occurs in a large proportion of cases that would recover
with even the simplest treatment; and, 2dly^ because, out of a good many hun-
dred cases of primary fever which I have treated, the fate of the patient, in a
large majority, has appeared to me to depend upon the effect which the remedies
employed produced on the affection of the tonsils. Indeed, I am quite inclined
to think, except in malignant cases, that where this is moderate, or can fairly
be kept under, the primary fever of the disease in question is in general a very
manageable one. Independently of those cases which prove fatal, merely from
the extensive sloughing of the tonsils and adjoining parts, every one who has
seen violent epidemics, must have remarked how much the formidable secon-
dary affections of the glands, cellular tissue, and even external skin at the an-
gles of the jaws, as well as the tendency of the inflammation to spread back-
wards to the larynx and trachea, or upwards to the internal ear and brain, are
influenced by the intensity of the inflammation with which the tonsils are
affected. It becomes, therefore, I conceive, a matter of the utmost moment to
ascertain accurately what are the most powerful means we possess for subdu-
ing this, in general the most prominent symptom of the anginose form of tbe
disease.

“ Before adverting to this point, however, it may be well to say a few words
on the distinguishing characters of the tonsillar affection.

“ The distinctive characters assumed by the inflammation of the tonsils in
scarlatina anginosa^ when compared, on the one hand, with severe cases of
cynanche tonsillaris^ and on the other with venereal or other common ulcers of the
same parts, are, it appears to me, sufficiently well marked. In the cases of
cynanche alluded to, the pain is from the commencement severe, and often becomes
excruciating, the affection frequently terminating in the formation of abscess.
In ulceration, again, the pain is either a raw feeling, or is felt principally when
pungent .'substances are swallowed. These characters are materially modified
in scarlatina. The pain, as long as the swelling does not extend to the surround-
ing parts, is, for the most part, comparatively moderate, even when the tonsils
are enormously swollen. I have repeatedly asked patients thus affected, whether
they experienced much pain in swallowing, and I liave most generally been

476

Progress of the Medical Sciences.

answered in the negative. I have never yet heard the pain complained of as
excruciating, and i have never once seen the inflammation proceed to the forma-
tion of internal abscess. When examined, also, the appearance of the parts is
very different. In cynanche, it is not so much the tonsils themselves which are
swollen as the anterior and adjacent parts, while, in the ulceration of the tonsils
I have alluded to, little swelling occurs, and we see generally more or less clean
excavations surrounded by inflammation. On the other hand, I would say, that
the chief characteristic of scarlatina anginosa^ is the inflammation, and particu-
larly the swelling of the tonsils themselves. Of course the other parts of the throat
are also inflamed, but this exists in other cases, and is most usually of secondary
importance.

“Of the state of the tonsils in scarlatina anginosa^ I think we may note three
degrees. Of the first kind, are those cases in which the swelling of the tonsils
is moderate, and their surfaces clean, the inflammation being apparently at the
same time considerable. These are not usually dangerous cases. In the second
degree, the swelling of the tonsils has increased a good deal, and we notice a
whitish (or sometimes yellowish) secretion, principally at the openings of the
ducts, but occasionally covering nearly the whole surface of the glands. This
appears to be an albuminous suostance. I have seen some of it which had been
spit up; it was something like the white of an egg inspissated, but was perhaps
tougher. The fever generally is more intense in examples of this description,
and the cases altogether are more dangerous than those of the first kind. Ex-
amples of the third degree are presented to us, when the tonsillar swelling
increases still farther, and ultimately ends in sloughing of a large portion of the
glands. In severe cases, the tonsils often meet, and completely hide the uvula
behind them. It is in cases of this last kind, I have no doubt, that by far the
greatest mortality occurs.

“It will be noticed, that in none of these divisions have I mentioned ulcera-
tions of the parts, which are so frequently spoken of by a great majority of
modern authors; and I have not done so, because I doubt whether these form an
essential part of, or are even common in, the throat affection of scarlatina anginosa.
No doubt, when the tonsils slough, a solution of continuity occurs, but this hap-
pens only in the third degree, and most frequently at a more or less advanced period
of the disease. The while albuminous matter seen in the second division, certainly
does not generally cover ulcers, for I have often observed the tonsils covered
with it one day, and quite free from it and clean the next; while, in cases that
never pass beyond the first degree, or during the time that the other two divisions
are passing through the first, the occurrence of ulcers on the tonsils is, I would
say, from very numerous observations, exceedingly rare.* A person who
examines the state of the tonsils superficially, especially when this inflammation
is declining, is very apt to be deceived on this point; for we can then often
observe a cup-like cavity, formed by the gland. An attentive examination of
this, however, will show that it does not arise from ulceration, but merely from
the centre of the swollen gland having sunk down more rapidly than the circum-
ference. Nor is attention to this point of slight practical importance; for I am
convinced, that by leading those who have not seen much of the disease, to
imagine that the healing of these ulcers forms an important part of the local
treatment, practitioners are apt to be betrayed into an inert and essentially erro-
neous practice. From all the observations I have made, I am inclined to think,
that, in this disease, the inflammation attacks chiefly the tonsils themselves,
whereas, in cynanche, it is the subjacent cellular tissue that is the principal seat
of the aifection.

“ Having made these remarks upon the characters of this affection, I shall
now make a few observations on its treatment. Most of the recent authors, who
have written upon this subject, agree as to the advantages to be derived from the

* I except here minute abrasions of the surface, which I have seen sometimes on the
uvula, soft palate, or lips, and which appeared to me to be produced when the nitrate of
silver I had been using accidentally touched them.

Special Pathology and Special Thefapeutics. 47t

application of the nitrate of silver. From my own experience, I would certainly
say that it is a local remedy of more importance than all the others we possess
taken tog-ether. Of course, from what I have already said, it will be understood
that I do not, as seems to be the case with some practitioners, limit its applica-
tion to the healing of ulcers which may appear,* or to the solutions of continuity
that are the consequences of sloughing. The former must certainly require very
few applications of the medicine, and if we wait till the latter has taken place,
in order to apply it, I am afraid we shall often have to lament the inefficacy of
this, as well as every other remedy. The important principle in using it, appears
to me to be, to apply it to the tonsils, for the purpose of subduing the inflamma-
tion existing there, that is, with exactly the saiiiC views as we apply the same
remedy in catarrhal or gonorrhoeal ophthalmia. When this is properly done,
either with a strong solution, or with the solid caustic, (the latter of which I
generally prefer, from its greater portability and convenience,) wm commonly
find, if the case is recent, and not very severe, that its effects in restraining the
inflammation and swelling are considerable.

“To do this remedy justice, my own observations would further lead me to
say that it requires to be applied early in the disease. At first, I had some hesi-
tation in using it before I bad previously premised local bleeding, &c., for the
purpose of subduing the intensity of the inflammation, I believe, however, that
this caution was unnecessary, or even hurtful, by causing the loss of valuable
time in the use of a less powerful remedy. The loss of twenty-four hours in the
application of the nitrate, makes the most material difference in its power of
controlling the inflammation. If it is not applied before the second day of the
eruption, I have found that, in severe cases, great difficulty is frequently expe-
rienced in preventing sloughing from taking place. When applied on the first
day of the eruption, its beneficial effects are much more evident; but I have
found its influence most decided when it has been applied before the eruption has
made its appearance. From my anxiety to get the caustic applied at as early a
period as possible, I have been in the habit, for some time past, of regularly
examining the state of the throat in all the other children of a family where one
had already become affected; and I have been not a little surprised to find, that
when the fever is about to be severe, the tonsils are invariably affected at least
twenty-four hours before the eruption appears, and sometimes two, three, or more
days previously. The day before the eruption appears, the tonsils, which may
have been previously merely somewhat tumid or swollen, generally become
considerably more so, at the same time that their colour changes from a pale to
a vivid red. By watching these changes, I have commonly been able to tell
within a few hours when the eruption would appear, even when there have been
no other premonitory symptoms. It is most remarkable, indeed, that the pre-
monitory symptoms in this disease bear no certain relation to the fever which is
to follow.

“ I recently took notes of a case in which the premonitory symptoms were
excessively severe, expecting the fever to be so also, and yet this passed off
very mildly, and the tonsils were only slightly affected. On the other hand,
again, in the same family, I requested that a little girl might be sent for from
school, in order that I might examine the state of the tonsils, scarlatina having
affected another of the children for several days before this. On examining this
girl’s tonsils, I found them greatly swollen and inflamed— in such a state, indeed,
that I had no hesitation in saying the eruption would appear within twenty-four
hours, which proved to be the case; and instead of being mild, this turned out a
very severe attack. Now, when 1 sent for this girl from school, she appeared
well in every respect. Her pulse was natural; she had no pain of the head, or
of the throat when she swallowed; there was no sickness or nausea; nothing,

* “ Inspect the throat (in scarlatina) both carefully and frequently, and treat the
ulceration there with dilute solution of nitrate of silver, or tiie chlorides,” — Dr. Baffi
ham’s concluding lecture in Med. Gaz, vul, xiv. p. 575,

41'8

Progress of the Medical Sciences.

in fine, but the state of the tonsils could have led me to the belief that a dan-
gerous fever was so nearly impending.

“ My practice, since I discovered the above to be the case, has been, every
morning to examine the tonsils of those who were living in a family where scar-
latina had appeared, and who had not already been alfected by the disease. The
instant I have discovered the tonsils beginning to be affected, as 1 have described,

I have touched them with the lunar caustic, and I have continued to do this
daily, until the fever has declined. The effects produced by it have been very
decided. When a severe case has been thus treated, the progress of the tonsillar
affection may in general be said to be as follows: On the day before the

eruption shows itself, the redness and swelling become more decided than
they have previously been; on the first and second days of the eruption, these
are still more increased; on the third and fourth days, the inflammation and
swelling continue nearly stationary, but the openings of the tonsillar ducts
show more or less of the white albuminous matter which has been alluded to.
After this, the swelling and inflammation begin rapidly to decline, and, about
the eighth day from the appearance of the eruption, the glands have in general
attained very moderate dimensions.

“ If my observations are correct, it will thus be seen, that the early and con-
tinued application of the nitrate does not prevent this local affection from passing
through what I have described as its two first degrees, but that it prevents it
entirely from passing into the third, and by far the most dangerous stage, that
of sloughing. The second degree, also, is, when thus treated, for the most part
very moderate, the power of swallowing being usually little if at all affected.

“Of course this practice is appplicable, to its full extent, only where the dis-
ease has already appeared in a family. But when I compare the ease with which
I have, by this means, been able to keep down the swelling of the tonsils, with
the intractable nature of similar cases, which 1 have not seen before the second
day of the eruption, it has forcibly impressed upon my mind the importance of
applying this remedy, in every instance, at the earliest possible period.”

As to the general treatment. Dr. Hamilton says that after the bowels have
ibeen attended to he has tried or seen tried no general remedies which appeared
4o him to have a decided effect in controlling bad cases of S. anginosa. “ I have
little doubt,” he adds, “that nine out of ten of the cases that prove fatal, do so,
directly or indirectly, from the state of the tonsils, and no general remedies I
have used have seemed to me materially to influence this affection when severe.
Jn the epidemic which I had an opportunity of treating in Edinburgh, in 1833-34,
J tried general bleeding in some severe cases, but I must confess not with such
success as to induce me to continue the practice, I believe, that when the pulse
at the commencement is full and very quick, a moderate general bleeding may
be used in this, as in continued fever, at least without disadvantage; but these,
it is to be remarked, are not in general the worst description of cases, the pulse
In the latter being often feeble or soft, and very quick even from the commence-
ment. Where this is the case, I would say, from my own experience, that
general bleeding requires to be used with considerable caution; and I confess I
am not satisfied that even the profuse local bleeding which occurred in case
second, was not rather hurtful than beneficial.

It will be observed, that I have used in all the eases related calomel and
opium. I have done this for two reasons; 1st, because I have thought their
joint action in determining to the skin might be beneficial; and ’2dly, because it
has always seemed to me important to guard against the occurrence of laryn-
gitis, which, perhaps more than any other complication, is apt to occur in a bad
state of the tonsils. — ibid,

27. On the Scarlet Fever Epidemic in Edinburgh in 1835-36. By Charles
SiDEY, Esq. — Mr. Sidey’s experience is derived from private practice, in w'hich
the disease presented itself in very different degrees of severity and complica-
l-ioiij The cutaneous efflorescence was in some cases very slight, and only par-

Special Pathology and Special Therapeutics, 479

tially diffused, whilst in others if was more generally or universally spread over
the body. In a few cases it exhibited a kind of deep purple or livid-coloured
patches. In several instances wdiere the throat was severely affected, the erup-
tion did not disappear for a much longer period than usual. The affection of
the throat exhibited every possible gradation from the slight erythematous
blush to a very formidable and destructive gangrenous inflammation. In the
more severe cases, the internal surface of the throat presented at a very early
period of the disease, an appearance like that which we could suppose to result
from its being rubbed over with caustic potash. When the slough separated,
the ulcers in the situation of the tonsils were, in several instances, so large and
deep as to appear capable of admitting the extremity of the under finger.

More or less inflammation or congestion of the throat, Mr. S. considers essen-
tial to genuine scarlet fever.

The affection of the throat and skin showed little or no kind of direct relation
in degree, one with the other.

The disease was most prevalent among the younger part of the population,
but when it attacked adults, it was more formidable, more frequently and
severely affected the fauces, and more rapidly run on to a fatal termination.

In several instances Mr. S. saw second attacks of the disease.

The sequeisc of the disease seldom assumed a very severe or dangerous cha-
racter in the patients attended by Mr. S. which he ascribes to the rigorous anti-
phlogistic measures which he uniformly inculcated during the first weeks of
convalescence.

“ In four or five cases the secondary inflammation of the submaxillary glands
went on to abscess, and in most of these instances, there occurred also a purulent
discharge from the ear. In no case has the inflammatory disease of the ear
produced such disorganization as to cause deafness.

“ Seven only of the patients whom I have attended during the present epidemic
have been attacked during convalescence with dropsy, or not one in twenty.
In four of these, this secondary affection appeared under a very mild and
manageable form; in a fifth it was very severe, though the patient ultimately
recovered; in the two others it proved fatal. In above twenty cases, I have
observed a form of secondary affection, with which I do not recollect to have
met with any description in authors, viz. a kind of rheumatic swelling and
inflammation of one or more of the joints of the extremities, as of the elbow and
knee, the wrist, the ankle, and the hip. This affection of the joints, has
appeared to me to have followed principally after the cases in which the skin
was much affected. It generally supervened during the first days of convales-
cence, and was frequently attended with very considerable pain and suffering.
I have been informed of one aggravated case, in which this secondary inflam-
mation was seated in the elbow and wrist, and went on to the complete destruc-
tion of these joints.”

The mortality in Mr. S.’s practice was seven in about 150 or 160 cases.

The treatment employed by Mr. S. he states to have been the following: —

“ After, in the first instance, strongly inculcating attention to cleanliness, to
keeping the patient cool, and his chamber well ventilated, I have insisted on
the antiphlogistic regimen being strictly followed out with regard to diet, and
have in addition forbidden the use of all kinds of fruits. I have made it also an
invariable rule to keep up a continued action on the bowels, during the whole
course of the disease, with gentle purgatives. The medicines that I have prin-
cipally employed for this purpose have been combinations of calomel with rhu-
barb, scammony and James’s powder, and infusion of senna with the sulphate
of magnesia. Whenever the tongue puts on, in a very marked degree, the well-
known and characteristic inflammatory strawberry appearance, I have deemed
it necessary to act upon the bowels by mild means, as by castor oil, and warm
emollient enemas. This point of practice I consider as of very great importance.
The necessity of free purging has always appeared to me to be fully evinced by
the very deranged state of the biliary and intestinal secretions, as manifested by
the green, black, and tar-coloured evacuations which were produced.

480

Progress of the Medical Sciences.

“ In the further treatment of the disease I have generally acted on the shin with
the spirit of Mindererus, or tartrate of antimony, in a mixture containing a
quantity of njtrous ether.

“ I have also constantly employed either tepid sponging, or the warm bath
itself, more frequently the latter. I have generally ordered the bath to be
repeated twice or thrice during the day. It has appeared to afford great relief
to the feelings of the patients, and was in many cases oftener repeated at their
own urgent request. In using it, the body was merely dipped in it for a minute
or two each time, and then quickly and thoroughly dried. A longer immersion
seemed to produce fainting, or a great tendency to it, followed by shivering. If
there appeared to be the least tendency to much affection of the throat when I
was first called, or at any period during the continuance of the disease, I always
instantly opposed it by free bleeding from the external fauces, by means of
leeches, repeated or not, according to circumstances. After the leeches dropped
off, I have generally ordered a warm poultice to be applied to the parts, and
have on many occasions, where the throat was much affected, continued a suc-
cession of them during the whole course of the disease, alternated with the occa-
sional use of the mustard poultice.

‘^As direct internal local applications to the inflamed ulcerated and sphace-
lating fauces, I have trusted principally to gargles composed of a solution of
sulphate of zinc with some powder of carbon; and in other cases I have employed
one of lime-water with a quantity of powdered cinchona diffused through it.

“A decoction of bran and one of these gargles was employed repeatedly dur-
ing the course of the day, and in children so young as to be unable to use them,
I have myself applied them, or ordered them to be very frequently applied,
during the twenty-four hours, by injecting them against the diseased surface of
the internal fauces, by means of the common syringe. I have found this to be a
certain and, at the same time, an easy method of applying washes and solutions
to the internal fauces in children, and one which is attended with comparatively
but slight inconvenience to the little patients.

“I never found it necessary to employ wine or stimuli of any description in
any of the cases that I attended.

“ During convalescence, I have been careful to preserve the bowels in a
favourable condition with the colocynth or rhubarb pill, and at the same time
inculcated an adherence to the antiphlogistic regimen for some time, together
■with the most careful possible avoidance of cold. To insure this last important
indication, I have generally insisted upon the necessity of my patients being
provided with an under-dress of flannel before they left their beds. It is to the
rigour with which these simple measures were enforced that I am inclined (as
before stated) to attribute the small ratio of severe secondary affections that I
have witnessed.

“ Four out of the seven cases of secondary anasarca yielded readily to a repe-
tition of active purgatives, with small doses of the nitrate of potass, and pow-
der of digitalis, and rubbing the surface of the body with hot spirits. One
of the cases was attended with convulsion, great difficulty of breathing, and
stupor. The urine was highly albuminous, and contained likewise blood to a
certain extent. He w^as treated with the usual diuretics, sinapisms over the
loins, friction with hot spirits, and a few leeches applied to the lumbar region,
the state of his constitution not indicating the use of the lancet. This case was
seen by Dr. Christison, at whose suggestion diaphoretics were tried but with-
out any marked advantage over the diuretics. The blood in the urine disap-
peared under the free use of the acetate of lead, and the patient is now in good
health. The sixth case resisted this and every other treatment that was adopted.
The patient, a boy of four years of age, presented no symptoms of internal in-
flammation, requiring the employment of general or local bleeding, but sunk
under the dropsy in a chronic form.” The seventh case was in a person who
had formerly passed through the dise'dse. During the second and fatal attack,
the eruption wms of a deep purple, and the fauces and nostrils w'ere extensively
ulcerated. — Ibid,

Surgery,

481

SURGERY.

28. Fracture of the Acetabulum. — The following case will be read with interest
not only on account of the rarity of the injury, but also from the interest
excited by the individual to whom the accident happened, and who was generally
known as the “ Wandering Piper.” The case is recorded by Dr. Charles
Lendrick of Dublin, in the London Medical Gazette^ for March, 1839.

“ Nearly a month since, at the desire of the Rev. Hugh Prior, I admitted this
person as a patient into Mercer’s Hospital. I was informed that he was of a
station in life much superior to that of his occupation; but that, for reasons which
could not be explained, he was not permitted to avail himself of his pecuniary
resources, but was required to subsist either on the profits of his assumed trade,
or on charity. His disease was phthisis pulmonalis, combined with acute
inflammation of the hip-joint. He had received a severe injury by the upsetting
of a mail-coach some years since, and had been then under treatment some
months for (as it was supposed) fracture of the neck of the femur. Since that
time he had been lame, but still able to take a great deal of exercise on foot,
both here and in America. The acute attack commenced about two months ago.
Just before his admission into the hospital, he had been under the care of Sir
Philip Crampton, who often expressed his surprise at the slight amount of the
shortening of the limb, w^hich did not exceed half an inch. This circumstance
wds explained by the dissection.

“ As there was nothing unusual in the progress of the case up to the time of
his death, on the 17th February, nor in the post-mortem appearances in the
thorax, I shall only allude to those of the hip-joint, the dissection of which was
performed on the 19th instant, in presence of my colleagues, Messrs. Read,
Auchinleck, Palmer, and Tagert.

_ “ There had not been any fracture of the femur, although the state of that bone,
forming the disease usually termed morbus coxae senilis., presented at first the'
appearance of one. The os pubis had, however, been fractured, and the edges
of this fracture, in overlapping, had caused, by their union, the rim of the pelvis
to be shortened nearly an inch between the symphysis pnbis and the inferior
spinous process of the ilium. What was very remarkable a portion of intestine
had adhered to the bone, probably being pinched between the ends of the fracture,
and had remained permanently attached within a bony cavity, presenting the
appearance of a hernia. The intestinal tube was, however, pervious; but the
large intestines were of much smaller calibre than those usually termed “ the
small.” The patient had not laboured under any abdominal symptoms during
life.

“ The ischium appeared also to have been fractured and to have become united.
The femur had obviously protruded through the rent in the acetabulum, and had
entered the pelvis. A bony case had been formed for its head; but a portion, about
the size of a shilling, was uncovered, except by ligament. The round ligament of
the joint was perfect and the other ligaments were thickened. Ulceration of the
cartilage of the head of the femur had obviously commenced; and to this, and
probably to the irritation of the obturator nerve by a spicula of bone which had
formed about it, the excruciating torment which the patient lately suffered might
be attributed.

29. On the Pathology of Burns and Scalds. By Samuel Cooper, Esq. — It is
to Baron Dupuytren that we are indebted for the first correct and important
explanation of tbe pathology of burns; a subject which, as throwing light on the
symptoms, and tending to improve the practice adopted in some stages of these
injuries, I deem highly deserving of farther investigation. In this hospital, you
are aware, gentlemen, that no opportunity has been omitted, of prosecuting the
inquiry by post-mortem examinations. The particulars of some of these I now
proceed to remind you of.

Scald of the Chest followed by Ulceration of the Duodenum. — Hannah Latter,
No. XLVIll. — August, 1839. 41

482

Progress of the Medical Sciences. ^

aetat. 8, was admitted December 18, 1838. About five weeks prior to this date,
she met with the accident, for which she was attended by a private practitioner,
who covered the injured parts with flour. The case went on promisingly for
three weeks, at the end of which she began to void a great deal of blood from
the rectum. At the time of her admission she was in a most reduced and ema-
ciated condition, and died on the 20th.

Post mortem appearances: Abdomen. — An ulcer, of about the size of a shilling,
in the duodenum, just beyond the pylorus; the deficiency in the parietes of the
bowel being supplied by the subjacent portion of the pancreas. Blood was
found in various places within the small intestines.

Chest. — Organs healthy.

Head. — Not examined..

Extensive and deep Burns of the Limbs. — Congestion of the Lungs and Brain^
and Effusion of Bloody Serum. — Amongst the cases of burns brought to the hos-
pital this winter, I may next notice that of Hannah Austin, aetat. 5, who, in
consequence of her clothes catching fire, was burnt on the left hand, arms,
thighs, and legs. On her admission there was great depression of the system,
coldness of the skin, and languor of the circulation. The feet were therefore
fomented, and some warm drink given. Flour was applied in the usual way.

On the day but one following her admission, the child became comatose, and
sunk. Before death, Mr. Taylor detected the existence of bronchitis.

Sectio cadaveris. — An accumulation of bloody serum in the cavity of the right
pleura; the lungs highly congested, and loaded with blood; the mucous mem-
brane of bowels pale; vessels of the brain exceedingly turgid, and a large quan-
tity of bloody serum at its base.

Burns on the Abdomen^ Chest, Arms, and Occiput, followed by Ulceration of the
Duodenum, and vomiting of Blood, ^c. — Mary Wright, aetat. 3, was admitted
into University College Hospital, with several burns of the above-mentioned
parts. As she was somewhat collapsed, warm stimulants were given, and the
burns dressed with flour. The next day vomiting came on, and for four days
the child voided from the stomach, considerable quantities of a dark brown
fluid, and complained of severe pain in the epigastrium. On the following day,
she vomited up blood, and, on the next, died convulsed.

Sectio cadaveris. — Traces of peritoneal inflammation on some of the intestines.
On raising the stomach, a large clot of blood was observed between it and the
mesocolon, circumscribed by adhesion of the adjacent peritoneal surfaces. On
breaking the adhesions, and separating the coagulum from the duodenum, the
contents of this bowel became effused through an ulcerated aperture, of about
the size of a halfpenny, which was situated in the posterior part of the intestine,
close to the pyloric orifice of the stomach. A quantity of coagulated blood was
found in the latter viscus, and also in the duodenum and ileum; and, besides the
ulcerated opening, there were three additional ulcers in the duodenum.

Burn of the Neck, Chest, and Arms, followed by Congestion of the Veins in the
Abdomen, Ulceration of the Stomach, Pneumonia, §rc. — Matilda Fitzwaylet, aetat.
9 years, was admitted January 17, 1839, with an ulcerated surface extending
over the front part of the neck, chest, and arms, and occasioned by a burn,
which happened three weeks previously to her admission. Symptoms of bron-
chitis had prevailed more or less ever since the accident. On the fifth and sixth
days after her entrance into the hospital, the difficulty of respiration became
very great, and she died on the seventh, four weeks after the occurrence of the
burn.

Sectio cadaveris.—\xi the abdomen the veins were all found very much con-
gested. There was an ulcer in the stomach, nearly cicatrized.

In the left side of the chest, old adhesions of the pleura observed. The lungs
wmre highly inflamed, congested, and almost hepatized. The bronchial mucous
membrane was much inflamed, and contained a purulent secretion.

A small quantity of fluid was found under the arachnoid membrane.

Remarks. — That many persons who meet with burns die comatose, or else
with great difficulty of respiration — asthmatic symptoms, as they were called —

Surgery. 483

were facts well known to surgeons many years ago. The cause of coma was
not, however, attempted to be explained, as it might correctly have been, by
reference to the congestion of the vessels of the brain, and the effusion upon or
within that organ, as subsequently demonstrated in post-mortem examinations;
while the old practitioners, instead of looking at the congested and even in-
flamed lungs, by which they would have been able to account rightly for the
oppression of the breathing, ascribed the latter frequent consequence of a burn
to sympathy between the lungs and the injured skin. This was the doctrine
which I used to hear inculcated by Abernethy.

The post-mortem examinations made by Dupuytren, of individuals who died
of burns, threw quite a new light upon the subject. They proved that, when
the sufferer perishes in the flames, or shortly after being removed from them,
marks of excessive congestion are usually observable in the intestinal canal,
although there has not been sufficient time for inflammation to commence. Not
only does the mucous membrane exhibit bright red patches — not only is it
gorged with blood, but the bowels contain a quantity of this fluid, which has
been extravasated. He describes the brain as being largely injected with blood,
and the fluid in the serous cavities of the body as presenting a reddish colour.
He represents the mucous secretion of the bronchial tubes as also bloody, and
their investing membrane as exhibiting a bright red colour, and streaked with
highly injected capillary vessels. It seemed to him as if the blood, suddenly
repelled from the skin, made an effort to escape through the pores of every inter-
nal surface.

Our second case exemplifies the truth of most of these observations, with the
exception that the mucous membrane of the boivels was pale, though the lungs and
brain were much congested, and a bloody serous fluid was copiously effused
within the cranium and the chest.

Dupuytren found that, if the patient died between the third and eighth days
after the receipt of the burn, traces of inflammation of the bowels, lungs, and
brain, were commonly noticed; but if the patient sank at a later period, or in
the suppurative stage, the mucous membrane of the intestines was generally
studded with patches of redness and ulceration, and that sometimes the mesen-
teric glands were enlarged.

As we have not met with such enlargement of the mesenteric glands in our
post-mortem examinations of burnt patients, a doubt is left in my mind whether
such enlargement, as remarked by Dupuytren, depended upon the burn, or upon
the effects of scrofulous disease existing previously to the accident.

The entire perforation of the duodenum by ulceration, exemplified in our first
case; the adhesion of the margins of the ulcerated opening to the pancreas; the
discharge of great quantities of blood from the rectum before the patient sunk;
and the blood found after death within the intestinal canal, and, no doubt,
the source of which was the considerable ulcer in the duodenum; appear to
me to be circumstances all deserving to be well remembered.

The vomiting, in our second case, first of a brown fluid, and as early as the
sixth day, of blood; the death of the patient at the end of the first week; the pre-
sence of several ulcers in the duodenum at this early date; its actual perforation
in one place by the ulcerative process; and the presence of blood in the stomach,
duodenum, and ileum, after death, are so many facts of great interest in relation
to the pathology of burns. Dupuytren’s observations would not lead us to
expect ulceration of the bow^els so early. As for the vomiting of blood, and its
discharge per anum, I am not aware that he has adverted to these occasional
consequences of burns at all.

Our last case, besides exemplifying several effects arising from visceral
inflammations, presents us with an instance of an ulcer of the mucous mem-
brane of the stomach nearly cicatrized.

These post-mortem investigations seem to me, gentlemen, not only to eluci-
date the causes of various symptoms, observed to follow burns, but to suggest
the question, whether, in the stages of burn, attended with congestion, or actual
inflammation of important internal organs, the taking away of blood from the

484

Progress of the Medical Sciences.

patient would not be the most likely means of saving the patient’s life. In
France, I know that the use of leeches, in certain stages of burns, is advocated
by some surgeons, as much as they are by certain practitioners here, in the com-
mencement of an attack of erysipelas. In the period of reaction, between the
third and eighth days, when the pulse is strong, and there is evidence of vis-
ceral inflammation having come on, what measure is so likely, I ask again, to
save the patient! Let the result of a moderate abstraction of blood be first
ascertained; and, if it be favourable, let the evacuation be repeated with circum-
spection.— bond. Med. Gaz. March, 1839.

30. Complete Anchylosis of the five superior cervical vertebrae to each other., and
complete dislocation backwards of the fifth from the sixths without fracture. — The
possibility of the occurrence of complete dislocation of the vertebras without
fracture, the first and second cervical vertebrse excepted, has been doubted by
high surgical authorities. The cases recorded by Lawrence, Sir Charles Bell,
Rush, and Ehrlich, and the following related by Mr. S. S. Stanley, are suffi-
ciently conclusive to show that such doubts are wholly unfounded.

A seaman, aetat. 37, fell backwards on his head on the deck. Immediately
afterwards he complained of severe pain in the back part of his neck and
between the shoulders, and of pain and numbness in the arms; his face was pale,
pulse weak. Under the influence of stimulants he rallied for a short time, but
subsequently sunk and expired fifty-five and a half hours after the accident.

The post-mortem examination showed considerable ecchymosis on the pos-
terior surface of the body from the occiput to the seventh dorsal vertebra, and
on dividing the integuments, a quantity of blood was effused into its texture.
There was also considerable displacement backwards of the fifth from the sixth
cervical vertebra without fracture. The little finger could easily be passed
underneath the last-mentioned vertebra, into the spinal canal; the body of the
fifth pressed severely on the spinal cord, and rested on the laminae and spinous
process of the sixth cervical vertebrae. The ligaments and intervertebral sub-
stance were all ruptured, and, when suspended from above, the parts were held
together by the vertebral arteries and spinal marrow, with its theca alone, the
theca vertebral is being uninjured.

The whole of the cervical vertebrae from the atlas down to the seat of dis-
location, were completely anchylosed. Not the least vestige of ligamentous
structure could be observed, with the exception of the capsular and occipito-
atlantal ligaments; the capsular ligaments and synovial membranes, when cut
into, were found to be so much thickened and altered in structure, as more to
resemble cartilage than ligament. No trace could be found whatever of the
apparatus ligarnentosus and lateral ligaments, connecting the occiput with the
atlas; neither was there any thing remaining in the form of the ligaments which
complete the articulation between the atlas and axis; but Nature, ever bountiful,
had formed a beautiful provision for the absence of the transverse ligament, by
an isthmus of bone, extending from the anterior aspect of the odontoid process
to the posterior concave surface of the anterior arch of the atlas; thus, in most
respects, answering every purpose for w’hich the transverse ligament is known,
although placed in a situation diametrically opposite.

The most remarkable feature in the whole preparation, and the result of a
former dislocation forwards, is the position of the atlas; which, on the right side
especially, is pushed forwards and upwards from off the articulating surface of
the axis, so as to cause the odontoid process to present itself nearly in the centre
of the circle of the atlas. A bridge of bone exactly half-an-inch in lengths and
varying from three to four lines in breadth, passes nearly horizontally forwards,
from the odontoid process to the atlas, and connects them together; the axis is
also pushed forwards in the same manner from the third cervical vertebra, but
not to so great an extent. Its length, measuring anteriorly from the superior
margin of the ring of the atlas to the inferior margin of the body of the fifth cer-
vical vertebra, is three-and-a-half inches. The diameter of the spinal foramen of
the atlas, from behind forwards, is exactly one inch and four lines, and the trans-

485

Surgery.

verse diameter one inch and half a line. The odontoid process, instead of ter-
minating* at its apex in a point, as it generally does, presents abroad and irregu-
lar ovoid form, measuring, transversely, half an inch, and from behind forwards,
including the bony bridge alluded to, one inch; its length is three-fourths of an
inch, and its distance from the posterior arch of the ring of the atlas only four
lines.— i>awce/, 23c? February, 1839.

31. On the varieties and Treatment of Fractures of the Bibs. By J. F. Mal-
GAiGNE. — “ From a review of our knowledge on the subject of fractures of the
ribs, M. Malgaigne concludes that the clinical and experimental history of this
affection is still a desideratum; all which is at present taught in the schools
being unsupported by any thing like proof. The author says that his attempt
will be to supply the necessary information; for which purpose he has studied
the normal figure of the ribs, he has instituted experiments upon the corpse, has
collected cases from the living, has procured pathological specimens, and has
gathered from books such information as was available for his object.

“ Causes of fractures of the ribs. External causes. The opinion generally main-
tained, that fracture of a rib takes place almost always towards the middle of the
rib^ is stated to be incorrect. M. Malgaigne says that the majority of such frac-
tures are seated in the anterior half of the rib. Direct causes may produce their
effects on all parts; but the anterior parts are the most exposed to their action,
the posterior portions being protected by muscles and by the scapula; the middle,
by the arm and the shoulder. And with respect to indirect causes, M. Malgaigne
has very often tried to break the ribs by a sudden and forcible pressure on the
sternum, but the fracture has always been in the anterior half, and generally
nearer to the sternum than to the middle of the ribs. Several reasons may be
given why this should be the case. The posterior extremities of these bones
being more elevated than the anterior, if, for example, the heel is pressed upon
the sternum, on a level with the insertion of the sixth rib, tbe pressure corres-
ponds posteriorly almost with the level of the tenth rib. The first effect of the
pressure upon the anterior extremity of the rib is to force it backwards and
downwards simultaneously; that is to say, to diminish in one direction, but to
increase in another, the interval which separates the extremities of the bone.
When fracture takes place, therefore, it is not in consequence of simple increase
of the curve, but because of the twisting which results from the depression of the
anterior extremity. As this movement takes place especially in this extremity,
it is quite natural that it should more particularly suffer. Again, the anterior
pressure acts upon the sternum beyond the anterior extremity of the rih, prolong-
ing the arch in this direction; but the posterior pressure acts particularly on that
part of the bone which is just anterior to the angle, and which projects so much
behind, that the body rests upon it in decubitus. Now, these two circumstances
explain why the centre of the arch, the curve of which is increased by the
fracturing force, is much anterior to the centre of the bone. And, lastly, anatomy
indicates and experience reveals another reason of the fact above stated. Pres-
sure does not act on all the ribs simultaneously; and those which are not pressed
upon, supporting the others, prevent them from yielding as much as if they
were isolated. Thus, for example, press with the hand upon the sternum, on a
level with the sixth rib; the sternum sinks, and, at the same time, approaches
the vertebrae. But, increase the pressure, the bone does not sink any further,
and its superior extremity, held firmly by the ribs, remains almost immoveable,
whilst the inferior is pressed towards the vertebrae. The ribs follow this move-
ment unequally; the sixth rib, being more directly subjected to pressure, bends
more; the seventh and the fifth, somewhat less, and so on. So that the point at
which flexion commences varies with each rib, and consequently, cannot be
always the centre of the arch which they describe, and, lastly, this point of
flexion cannot be very far separated from the sternum, because of the resistance
of the neighbouring ribs. From this binding together of the ribs when they
resist pressure on the sternum, it happens that in almost every case several ribs
are simultaneously fractured, when the cause of such fracture is indirect; and,

41*

486

Progress of the Medical Sciences,

on the other hand, as these fractures always take place in the anterior half of
these bones, a series of fractured ribs in the vicinity of the sternum, excepting
where they may have been caused by the wheel of a carriage passing over the
ribs themselves, are almost inevitably dependent on an indirect cause. Many
individuals suffered fractures of the ribs in an enormous crowd, assembled on
the Champs de Mars, in 1837. Of twenty-three who died, seven had fractured
ribs. The number of ribs which w^ere broken varied from two to thirteen in
the same individual; and all the fractures were anterior, and between one inch
and a half and two inches and a half from their cartilages. But a single rib
may be broken by an indirect cause; in which case the pressure has acted sole-
ly upon the cartilage, or upon the extremity of this rib.

“ With regard to the internal causes of fracture of the ribs, we can here only
allude to several cases, which M. Malgaigne has collected, of fracture taking
place during cough, in cases where there does not appear to have been any
peculiar fragility of bone. The individuals to whom the accident happened
were all, however, somewhat advanced in years. Drs. Gooch and Graves are
alluded to by the author as having published cases of this description. In a
diagnostic point of view, the fact, possibly of less rare occurrence than is sup-
posed, should not be lost sight of.

“ There are three principal kinds of fractured ribs: 1. Incomplete fractures,

2. Simple fractures. 3. Multiple fractures.

“ 1. Incomplete fractures. These may occupy the inferior or superior half of
the bone, or the internal or external surface. Fractures of the latter kind are
simple or multiplied, most generally affecting the internal table, but sometimes
the external alone. Direct or indirect causes produce them, and several ribs
are commonly affected at the same time. These fractures are so readily pro-
duced, either upon the entire corpse, or upon a rib isolated and separated from
the soft parts, that it is difficult to resist the inference that incomplete fractures
of the ribs are of much more frequent occurrence than we appear justified, from
our actual knowledge, in supposing them to be. Two causes may account for
our inability to decide this doubt: the negligent mode of diagnosticating frac-
tured rib, and the infrequency of autopsies. But there are cases of incomplete
fracture on record, occupying the various situations already mentioned. Such
cases are detailed by M. Malgaigne.

“ 2. Complete simple fractures. These are either oblique or transverse, the frac-
ture being clean: or they are very irregular, each fractured surface being covered
with projecting points and angles. ,

“3. Multiple fractures. These fractures, although scarcely recognized, are
probably as frequent as the second variety. The double fracture is sometimes
incomplete. Complete fracture may be associated with an incomplete fracture,
or the fracture may be complete in two situations, or there may be three or even
four fractures in the same rib. In the “ Musee Dupuytren,” two anatomical
specimens are preserved, where several ribs are broken together; in one case, all
the fractures are simple; in the other, they are double. Of nine anatomical spe-
cimens, in the possession of M, Malgaigne, five exhibit a consolidated simple
fracture; two present double complete fractures of the same rib, the middle
fragment being from three to four inches in length; one shows the traces of three
fractures, the hindermost of which, close to the angle of the rib, appears to
have been complete, and the other two, half an inch and four inches anteriorly,
are incomplete. In the last specimen are traces of four fractures: one towards
the angle of the rib, complete; a second incomplete, and half an inch more an-
terior; and others, more anterior still, which appear to have been complete. The
callus of complete fractures may be readily distinguished, however small may
have been the displacement: it surrounds the rib like a rough and projecting
ring; whilst in incomplete fractures the external face (unbroken in all the speci-
mens seen by M. Malgaigne) shows no vestige of bony deposite, and the
imperfect ring of callus is only seen on the inner surface or on the borders of
the bone.

'‘'‘Displacements to which fractured ribs are subject. In the incomplete fractures^

Surgery. 487

when there is but a fissure in the bone, whether longitudinal or transverse, there
is no displacement. M. Malgaigne broke off the inferior border of the rib with
the blow of a hammer, and here there was displacement; and he has a specimen
of a fracture of the internal table and diploe, effected by himself, the external
table being somewhat depressed opposite the fracture, a depression which would
probably escape observation on the living subject. But the most important cir-
cumstance in this specimen is, that the anterior fragment of the inner table pro-
jects inwards about a line, and that this projection cannot, by any movement, be
replaced. By compressing the extremities of the rib, so as to increase its curve,
the internal fragment was in some degree replaced; but whilst increasing the
pressure, so as to complete the reduction, the external table was broken, and
the fracture then rendered complete. A similar result was attained from frac-
turing the external table and the diploe, without injuring the internal table. A
fragment projected externally, which could not be reduced by any means. M.
Malgaigne has an anatomical specimen representing, he thinks, this fracture;
and he supposes that such an external projection might take place as to be evi-
dent, on examination, through the soft parts. The author forced in the seventh
rib by a violent blow with a hammer. In the situation of the blow, an angular
concavity could be felt, instead of a fracture: the internal table was broken in
two points, separated from one another about two inches and a half, and the
fragment resulting from this fracture was only adherent by its centre to the rib.
Cheselden speaks of having found, in autopsies, upon the external surface of the
ribs, an impression of the thumb and four fingers of nurses. It is supposed that
the condition of parts may have resembled that just described. M. Malgaigne
does not maintain that, even in multiple fractures of this kind, displacement
always takes place. When the depression affects several ribs, as happens from
the wheel of a carriage, the diagnosis is immediately evident. A depression of
various extent and size exists; and if, in examining it with the fingers, no pro-
jection of any fragment is felt, if the pressure increases for an instant the depres-
sion, without producing any projection, the existence of an incomplete multiple
fracture of the internal table may be diagnosticated.

“ In the simple complete fractures^ there may often be no displacement, when,
for instance, the periosteum is untorn, or the fracture very serrated; but displace-
ment as often occurs, although, frequently, not to such a degree as to be per-
ceptible through the soft parts. Of such displacement, M. Malgaigne has
described examples in his possession. In one case the posterior fragment projects
inward for nearly a line, and upwards in about the same extent. In a second,
the displacement is of the anterior fragment, downwards and backwards about
a line. A third shows a projection of the posterior fragment outwards. In one
specimen, preserved by Dupuytren, several ribs are affected with simple frac-
ture; the fracture is oblique, from one border to the other, but in opposite direc-
tions, and the displacement varies in consequence; thus, in the first of the
broken ribs, the anterior fragment projects upwards; in the second, it is depressed
beneath the posterior; and in the third, the displacement is similar to the first.
In a skeleton, some of the ribs of which had been fractured during life, at about
four fingers’ breadth from their cartilages, the appearances were as follows:
The anterior fragment of the fifth was carried inwards and downwards, the
superior interosseous space being evidently diminished backwards; the anterior
fragments of the third and fourth were depressed inwards; there was no dis-
placement of the second, and the fracture could only be estimated by the rough-
ness of the callus. Others have noticed such union as clearly indicated
displacement: some attributed this to the treatment employed, the pressure
recommended by Petit. But this explanation is inadmissible, as evidence of
displacement exists when no such treatment was employed. Similar displace-
ments are effected by blows upon the sternum and ribs of the corpse — experi-
ments which have been frequently made by M. Malgaigne.

“ Multiple fractures. These, when complete, sometimes occur without displace-
ment; more commonly there is displacement of one of the fragments, the other
remaining almost in place; and sometimes all the fragments are simultaneously

488

Progress of the Medical Sciences,

displaced. M. Malgaigne regards external violence and the configuration of
the fracture, as the causes of the displacement. An external shock, for instance,
partly fractures a rib: it acts first by thrusting it inwards; a greater force breaks
the internal table and diploe, the denticulated form of the fractured surfaces pre-
vents the return of the rib to its original position, and hence there remains a
depression of the unbroken external table of the bone. Is the fracture complete?
If the fracture is transverse and smooth, there is commonly no displacement,
the bone returning, by its elasticity, to its original situation. But exception
must be made for fractures occurring very near the sternum; partly in conse-
quence of the ligamentous attachment of the ribs to this bone, the anterior
fragment moving inwards and outwards, and which, when it has been carried
inwards, has not, in consequence of the articulation, the elasticity of the pos-
terior fragment. The case is similar, where a broken portion has become bent
by a second fracture, either complete or incomplete; there remains no elasticity
by which it may regain its position. When the fracture is oblique, the direction
of its obliquity commonly determines that of the displacement. The denticu-
lated extremities of fractured ribs are the most frequent among the causes of
continued displacement: but with regard to fractures near the sternum, a special
cause of displacement in a certain direction exists, and which also tends to re-
produce displacement when it has been remedied. Pressure upon the sternum
depresses the sternal portion rather than the other, and this pressure tends also
to carry it downwards, motion in the two directions sometimes coexisting.
This (the sternal) portion being depressed, the posterior fragment projects
simply because it remains in its place. Decubitus on the back, a circumstance
well deserving the attention of the surgeon, augments this projection, the pos-
terior fragment of the ribs being pushed forwards; and if the patient lie upon
the fractured side, there is still greater projection. The nearer the fracture is
to the sternum, the more evident are these circumstances, and most particularly
in fracture of the cartilages. M. Malgaigne has found, in the last case, that by
varying the pressure upon the ribs, the anterior or posterior fragment might be
made to project; a fact from which he has derived a method of treatment, to be
noticed.

“ The diagnosis must be inferred from what has been said concerning the kinds
of displacement. It is frequently very difficult, and always requires very great
care. There are some special causes of error, which should be borne in mind.
The insertions of the obliquus descendens and serratus magnus muscles might
give rise to the notion of displacement, in consequence of their abrupt projection
beneath the finger, especially when pain causes any spasmodic contractions in
these muscles; and in some subjects there are remarkable projections at the
union of the cartilage with the bone of the rib.

“ Treatment. The treatment of fractured ribs iS shown, by what has preceded,
to be less simple than most surgeons have conceived it to be. The fractures
without displacement require only to be kept at rest; those with displacement,
and which are not disposed to be displaced when reduced, require reduction, in
addition; and when there is a tendency to displacement after reduction, there is
a third indication to fulfil, i. e. to prevent such secondary displacement.

“ 1. Means of keeping the ribs immoveable. The rules laid down for using the
bandage for the trunk are, that it is indispensable when it alleviates pain caused
by respiratory efforts; that when there are no such pains, it is needless to em-
ploy the bandage; and that if pain continues notwithstanding its use, it is both
useless and injurious. In individuals with a. large chest and vigorous constitu-
tion, the circular bandage is safe. M. Malgaigne prefers the following mode of
applying it. Surround the chest, first of all, with a common bandage, and
apply over this a piece of cere-cloth (sparadrap), about three fingers broad, and
sufficiently long to pass twice round the body. But in feeble individuals, with
narrow chests, agitated by chronic coughs or paroxysms of asthma, the indica-
tion is to confine the constriction to the injured side; an indication which it i&
not easy to fulfil. Decubitus upon the injured side would be very useful, could
it be borne: if not, a derai-cuirass, made by soaking a bandage in an amylaceous

Surgery. 489

decoction, might fulfil the proposed indication. But on this point M. Malgaigne
only throws out suggestions, not having made it the subject of experiment.
But he tried, in the following manner, to limit the action of the thorax by bands
of cere-cloth (sparadrap). The commencement of one band was appplied on a
level with the anterior extremity of the seventh rib of the right side, thence
passed around the left side of the thorax, beneath the left scapula, and over the
right shoulder: from this point it was passed a second time around the left side
of the thorax, ending on a level with the crista of the right ilium. The costal
respiration of the left side was thus evidently impeded, whilst it continued quite
free on the right side. It would appear that the left ribs might be much more
directly acted upon, by surrounding them with an oblique bandage, the two ends
of which should cross one another at the right hip; but in this case the anterior
part of the bandage, by compressing the abdomen, would interfere materially
with the diaphragmatic respiration, which it is very important in these cases
properly to manage. Or again, one side of the thorax might be acted upon by
means of the spring of a hernial truss, the sternum and the spine being points on
which the spring should press. A strap passing over the opposite shoulder
might be used to support this, and, if necessary, a large vertical splint might be
placed between the centre of the spring and the convexity of the ribs. This
apparatus is applicable for the fulfilment of another indication, hereafter to be
noticed.

“ 2. Means of reducing the displaced fragment. In simple or double fractures,
with depression of one fragmeut, the indication may consist only in elevating
the depressed portion. But in some cases there is an actual projection of the
other fragment outward, produced by the bad position of the patient ; but
change of position suffices to rectify this. With regard to the former indication,
M. Malgaigne observes that he had frequently tried the experiment on the corpse,
of pressing gently downwards the fragment which remained in its proper situa-
tion, until it came in contact with the depressed fragment. He found that the
inequalities of the two broken surfaces fitted into each other; and that, on remov-
ing the pressure, the elasticity of the rib brought back into its right position the
former fragment, bringing the depressed portion with it. To effect this, certain
conditions are necessary: if the fracture occupies the middle of a true rib, or is
further backward, it is of little consequence which is the depressed portion; if
it is more anterior, the posterior fragment alone possesses sufficient elasticity to
produce the above effect, so that, were this fragment itself depressed, it would
not be really elevated. With regard to the false ribs, whatever situation the
fracture may occupy, the anterior fragment can only be elevated by means of the
posterior. Fortunately, by virtue of this elasticity, the depression of the former
is much more frequent than that of the latter. Two cases are related in support
of these views of treatment, derived from experiment upon the corpse. In one
of these, although the reduction was not accomplished, the manipulations caused
a sudden and remarkable relief of pain, leading to the belief that some irritating
portion of bone might have been removed from contact with the lung. Remaik-
ing on the cases alluded to, M. Malgaigne observes that it required but in a
trifling degree to diminish the depression of one fragment to cause an instanta-
neous cessation of most acute pain, very probably by disengaging the lung from
a fragment of bone which was pricking and irritating it, and bringing back the
projecting piece beneath the costal pleura. It is to these depressed portions of
bone that may be attributed the acute pains and the visceral inflammations which
sometimes accompany fractured ribs; and if it is remembered that, frequently,
whether the fracture be complete or incomplete, the displacement may not appear
at ail externally, whilst there is a considerable prominence of a portion of the
inner table of the bone, we may be disposed to regard this circumstance as of
more importance than has hitherto been the case. Morbid anatomy confirms
(although not with much proof) the above explanation. M. Malgaigne contends
that the necessity is almost as great for removing fragments of bone from the
lung, as for removing them when driven into the brain. He alludes to the
various methods which have been suggested for effecting this object; and he

490 Progress of the Medical Sciences.

suggests the following: to take a needle, covered like a tenaculum, to plunge it
as far as the superior border of the depressed fragment, and thence to pass it
over the inner surface, almost as far as the channel in which runs the intercostal
artery, employing the instrument then as a simple elevator. The incision may
be thus avoided; and such a puncture is very harmless.

“3. Means of preventing return of displacements. In fractures near the sternum,
there is actual danger of this occurrence; and its causes are decubitus upon the
back, and particularly on the injured side. The twofold indication is to keep
the healthy side of the thorax forwards, so that the fragment which is attached
to the sternum may be drawn in the same direction, and to keep up a constant
pressure upon the portion which projects, equal in amount to the resistance
atforded by the elasticity of the rib. The former indication is quite fulfilled in
serious cases, by decubitus on the healthy side; and then, also, the little disposi-
tion of the ribs to move would render the second almost useless. But in less
important cases, where the patient wishes to move about, and to walk, the two
indications are fulfilled simultaneously by a truss for hernia, with a long spring,
one extremity of which presses posteriorly upon the projection of the ribs, on
the sound side; the other anteriorly, upon the posterior fragment itself. To
obviate the injurious effects of prolonged pressure, compresses may be employed.
— B. ^ F. Med. Rev. April, 1828, from Archives Gen. de Med. July and August,
1838.

32. On the application of Raw Cotton to Erysipelatous Surfaces. — M. Reynaud,
chief surgeon of the French marine, and professor of clinical surgery has pub-
lished a long paper in a late number of the Journal des Connaissances Medico~
Chirurgicales^ on the good effects of applying raw cotton to erysipelatous sur-
faces. He was led to try it in such cases, from its acknowledged utility in
many examples of burns; all the forms of which, from a simple scalding of the
surface to a complete adustion of the integuments, M. Reynaud has for a num-
ber of years treated with covering the parts with cotton. In the milder form of
the accident, the cotton often soothes almost instantaneously the severe pain,
and thus mitigates or checks the febrile excitement which is so apt to ensue;
while in the more severe cases, although it does not prevent the suppuration
and sphacelation, these processes usually go on more quickly and more favorably
under its application. If the remedy is so decidedly useful in burns, we cannot
be surprised at its utility in erysipelas. The burning, stinging pain of the
disease, we are informed, very speedily abates, the surface becomes moist and
perspirable, the swelling and redness diminish, and the skin recovers its healthy
pliancy and softness, with little or no subsequent desquamation of its cuticle.
The constitutional symptoms of erysipelas being always in a great measure
proportionate to the severity of the local distress, they are necessarily much
mitigated, and all the functions quickly resume their normal rhythm. M. Rey-
naud informs us that he has successfully used the cotton medication in all the
various forms of erysipelas, idiopathic and traumatic, without regard to the seat
or duration of the disease.

The modus operandi of this remedy is, according to him, by promoting a free
exhalation from the surface, and by confining the moist and warm atmosphere,
thus induced, around the inflamed surface. A steady and uniform temperature
is thereby maintained, and the contact of the air and light — two potent stimu-
lants of the skin — is prevented. The cotton application alone is not sufficient
however, it must be admitted, in all cases of burns; nor ought it to supersede
the use of other local remedies, when these are deemed proper.

When used, it ought to be well carded, and freed from all roughnesses or
foreign bodies. The affected part should be enveloped in a moderately thick
cushion of it, and a roller should be then passed loosely around, to confine it in
contact with the skin.

Fourteen cases are narrated by M. Reynaud; in proof of the efficacy of the
cotton application. In four of these the erysipelas affected the face. The con-
stitutional treatment consisted in the use of blood-depletions, of purgatives and

Surgery, 491

refrigerant diuretics. The cotton was applied to the inflamed parts and kept in
its place by the night-cap and by handkerchiefs. All the patients recovered. It
is proper to observe, that none of these four cases appear to have been severe.
In the remaining ten cases, the erysipelas affected the lower extremities.—
Med. Chirurg. Rev. January, 1839.

33. Deafness from Disease of the Lining Membrane of the Tympanum. — Use of
the Acetate (f Lead. The following interesting case of disease of the lining
membrane of the tympanum relieved by the use of acetate of lead is related by
Mr. Arnott in the London Medical Gazette^ (April 13, 1839.)

Thomas Parker, aetat 19, was admitted into the Middlesex Hospital January
28th, with ulcer of the leg. He was deaf, and his countenance was characte-
ristic of that infirmity. On an accurate examination of the degree to which this
sense was impaired, a watch was employed, the ticking of which can be heard
at the distance of 20 feet. Parker could not recogniz - it with his left ear further
off than five inches; with the right., not further than nineteen. There was no
redness, swelling, or rawness, of the parietes of the external meatus. Not the
slightest appearance of wax in the left, and but a very trifling in the right ear.
The membrana tympani in each was gone; the cavity of the tympanum in both
was filled with a milky secretion, devoid of offensive odour. This having been
in some degree removed by syringing the parts, the lining membrane of the
tympanum was seen to be more tumid and redder than natural. The patient
had been deaf since he was a child; he had always had more or less discharge
from his ears, and had been told that some bones had come away. Repeated blis-
tering, and a variety of injections, had been ineffectually tried % him.

Besides the destruction of the membrana tympani, and a loss of the bones of
the ear, the chief existing morbid action seemed to be seated in the mucous
membrane of that cavity itself, unconnected with disease of the temporal bone.

With the view of correcting this, a solution of the acetate of lead — six grains
to the ounce of water — was ordered to be dropped into the ear twice daily, and
the parts to be syringed with it once daily. Under this treatment the improve-
ment was unexpectedly rapid. In five days the hearing distance of the left ear
had increased from five inches to two feet ten inches; in the right, from nineteen
inches to seven feet five inches; and (without taking the intermediate periods)
in three weeks, in the left ear, to fifteen feet; and in the right to eighteen. Long
previous to this, however, he was quite able to take part in conversation, and
his countenance had assumed an expression of intelligence, most singularly
contrasting with its former dulness and apparent stupidity. The discharge now
ceased, and the lining of the cavity of the tympanum had lost that swollen and
pulpy appearance it had previously presented. And probably connected with
these changes, the patient was now able to cause air to pass from the throat
out of the external ear, which in the first instance he could not do.

The acetate of lead is a safer application to the ear than the more powerful
astringents; and the present case shows its beneficial effects in remedying a
diseased state of the mucous membrane of the cavity of the tympanum. This
diseased state removed, hearing was restored to a degree which, perhaps, you
might not have expected, if you previously supposed the existence of the mem-
brana tympani absolutely essential for hearing.

34. Congenital Club-Foot. — A paper by Dr. Krauss, was read to the Medical
Society of London which contains some views, worthy of notice. Dr. K. is of
opinion that the anatomy of congenital varus is intimately connected with its
cure, and believes, in opposition to Scarpa and Dr. Little, that the displacement
of the astragalus is one of the principal and most characteristic symptoms of
varus. The ascertainment of this displacement, whether it be of a primary or a
secondary origin, was highly important, as on it wmre founded the two principal
conditions of the mechanical instrument employed in its cure. With all defer-
ence to the merits of Dr. Stromeyer, he (Dr. Krauss) did not consider the
methods and principles of that physician’s practice to be so perfect as not to

49-3

Progress of the Medical Sciences,

admit of improvement. Regarding the Stromeyerian method of dividing ten-
dons with two punctures of the skin, and with a concave or convex fistula knife,
Dr. Krauss observed, that the convex knife could be used with advantage, only
when the tendon to be divided was prominent, the skin covering it not too thin
and tight, and the part to which the tendon was attached of small volume. If
the tendon was not prominent, and more of a flat than of a rounded shape, it
was difficult to encircle the tendon at once by a concave knife, and thus it was
often preferable to use a short convex knife, with a straight back, if it w'as pos-
sible and required to press down the skin on one side of the tendon, in order to
introduce the knife deep enough to pass through the whole of its body. Al-
though it was of no particular consequence to make two punctures of the skin,
yet, as the operation could be more easily performed by making one punc-
ture, the former method need not be adopted. Dr. Little sometimes us^d a
convex, sometimes a concave knife, for the purpose of dividing the tendo
Achillis. Dr. Krauss considered that a concave knife was not convenient for
that purpose, because the front surface of the tendon was flat, and its posterior
surface convex; and, again, in dividing the tendon, even with a convex knife,
the part of the tendon corresponding with its greatest convexity becomes divided
the last. Dr. Krauss also objects to the mode of introducing the knife flat-
ways, and then turning its cutting edge towards the tendon, for he says that by
this proceeding the parts are apt to be injured by the turning of the blade of the
instrument. It was inconvenient to place the patient in a chair when the tendo
Achillis was to be divided, inasmuch as the back surface of the leg was not
brought towards the face of the operator, and it was, therefore, impossible to
make an accurate examination either during or after the operation. In proof of
the justice of these remarks. Dr. Krauss referred to the fourth and fifth cases of
Dr. Little, recorded in The Lancet, in which it was necessary for the operations
to be repeated, in consequence of some fibrous strings remaining undivided by
the first operation.

The mechanical part of the treatment of club-foot was by far the most import-
ant and difficult. He (Dr. K.) considered that the footboard of Stromeyer was
deficient, as it possessed no proper means of fastening the foot, or of straightening
the curve which the foot forms in varus; as it only acted by a fixed pressure, and
did not admit either of the patient’s walking or standing.

Dr. Krauss insisted upon the necessity of distinguishing accurately between
congenital and non-congenital varus. In the latter, as the displacement and
change of shape of the tarsal bones did not arrive at such a high degree; as the
ligaments were looser, and as the deformity was almost maintained through the
contraction of certain muscles, it followed that the cure was, in general, possi-
ble, up to the,age which permitted the division of tendons; while on the con-
trary, the cure of congenital varus depended not only upon the age and consti-
tution of the patient, but also upon the degree of displacement and change of
shape of the tarsal bones, and the degree of the rigidity of the ligaments.

Dr. Krauss considered that bony vegetations did not often prevent the cure of
varus; the articulating surfaces, it was true, had partly lost their polish, and
were rough, but the efforts of nature powerfully assisted in polishing them again
after the straightening of the foot had been effected. Indeed, he believed that there
were few cases ot congenital varus previous to the age of thirty which did not
admit of cure. The cases of congenital varus cured by Stromeyer, and related in
his recent publication, referred to children of one, two, and five years of age, only
one as late as the ninth year being recorded, and in this the deformity existed
only in a slight degree. In the case of congenital varus, presented by Dr. Little
to the Society, at the first meeting of the session, as the most difficult he had
cured, the foot assumed its natural shape in eight or nine weeks after the divi-
sion of the tendo Achillis, and was, therefore, evidently a case of a slight kind.
The means of curing aggravated cases of congenital varus consisted in a proper
mechanical treatment, for which purpose the instruments of Stromeyer were
insufficient.

Dr. Krauss has never had an opportunity of examining any tendons after
division in the human subject, but he has made a variety of experiments on

Surgery, 493

rabbits and other animals, and he had found that the uniting substance was of a
fibrous texture, the fibres running rather in a transverse than a longitudinal
direction, and formed a structure quite as strong as the tendon itself. He had
often found that the intermediate substance was of much larger volume than the
tendon. In one case, in the human subject, in which he had divided the tendo
Achillis, inflammation of the intermediate substance, of an acute character, set
in three or four weeks after the operation. The new structure was, by this
means very much thickened; the thickness was eventually considerably, though
never entirely, reduced. In another instance he had felt the new tendon to be
very hard to the touch, as though there was a deposit of cartilage in it; and, in
another case in which inflammation and suppuration followed the division of the
tendon, union eventually took place, but it was three months before the limb
could be exercised.

Mr. Bryant said that the experiments just alluded to, differed in their results
from those of Sir A. Cooper, who had found that divided tendons invariably
united by bone.

Dr. Krauss replied, that as far as he knew, in the experiments on the division
of tendons, made by various continental operators, bony union did not follow. —
Lancet^ 13th April, 1839.

35. Case of Ranula in which the left submaxillary gland was extirpated, — The
following operation performed by J. G. Malcomson, Esq., Ass. Surg. Madras
Establishment, is so remarkable as to deserve to be put on record, though we
would not wnsh by so doing to be supposed to recommend a recourse to it under
similar circumstances.

“ In the beginning of 1828, a sickly-looking Hindoo boy, nine years of age,
was brought to Chicacole from an unhealthy hill district, on account of a swell-
ing which extended from one ear to the other, over the angles of the jaw and to
the sternum, near which it was more distended than above, and slightly pendu-
lous, so as to admit of being raised from the skin covering the superior
extremity of the bone; it was quite soft, and evidently contained a ffuM. The
disease commenced about a year before, below the jaw and a little to the left of
the chin, and had gradually increased downwards, and up to the ears. Tbe
patient stated, that for some time before the appearance of the tumour, there had
been a discharge of pus half an inch behind, and lateral to the mouth of theiduct
of the left submaxillary gland, where there was a depressed cicatrix, abouta bpe
in diameter, on the formation of which the swelling commenced. Near the'ciba-
trix, there was a carious tooth. A very slight discharge of saliva from the left
submaxillary duct could still be observed. There was no swellintr in the
mouth; but a hardness could be felt below the jaw, a little to the left side, and
there were several scars in the centre of the swelling, caused by repeated appli«
cations of the actual cautery.

“ I concluded from these facts, that the submaxillary ducts or gland having
been inflamed, probably from the irritation of the diseased tooth, the pas-
sage of the saliva was interrupted, and making its way into the loose cellu-
lar substance of the throat, had gradually distended the integuments to the enor-
mous size above described. In this view of the case, the following questions
suggested themselves as to the probable termination of the complaint, if left to
itself; viz. whether there was any chance of its ceasing to increase by the action
of the absorbents, or was it more likely to separate the skin from the chest, or
to burst into that cavity, the windpipe, or externally^ There could be no doubt,
oji the most favourable supposition, that it would for ever prevent the patient
from gaining his own subsistence.

“ A tentative puncture was made into the most prominent part of the swelling,
by which 20 ounces of a glairy, transparent fluid, of a light brown tinge, was
discharged; a hard, movable substance was then felt within the integuments; it
was extracted by enlarging the opening, and proved to be a part of the fluid
which had become inspissated. The real nature of the case, and the absence
of any other disease having been ascertained, the opening was left free, in hopes
No. XL VIII. — August, 1839. 42

494

Progress of the Medical Sciences.

that some contraction of the mass of loose skin would take place, and that a
part of it would again adhere to the subjacent parts, but in consequence of the
collapse of the sides, the discharge, which was mixed with blood and matter,
was not free, and had to be pressed out every morning. The patient then
absented himself for some days, during which the wound healed, the fluid again
collected, and another puncture was made in consequence. After this the skin
of the cheeks appeared to unite with the muscles, from which it had been sepa-
rated, and the second object seemed in part to be gained; I therefore on being
suddenly ordered to another station, recommended him to a medical friend, and
instructed the people to squeeze out the secretion daily.

“ I heard no more of him till the 15th of March, when he arrived at Viziana-
gram, and both he and his relations earnestly requested me to relieve him. The
opening had again closed; a new puncture was made, and several ounces of fluid
of a lighter colour, and thinner consistence than before, were evacuated. A tent
was left in the wound, some inflammation followed, and a good deal of matter
was discharged along with the glairy fluid; the skin contracted a little, but it
was evident, that little could be expected from this plan. Having procured a
very fine probe, I found it passed into the duct of the gland, and some saliva
flowed from It: this diminished my confidence in the opinion I had formed of
the disease, but convinced me, that it could not be cured by endeavouring to
restore the communication by the mouth, and removing the swelling by punc-
ture and pressure. I therefore resolved to remove a portion of skin constituting
the front of the sac, ascertain if the fluid came from the gland, and take such
farther measures as might be necessary.

“ On the 30th, 1 placed him on a table, and punctured the tumour three inches
above the sternum; and after the fluid was evacuated, cut away an loval portion
of the skin (of the size of two and a half by two inches,) which was much
thickened from the cicatrices of the cauteries and punctures. The throat now
exhibited an extraordinary appearance: from behind the ears, over the angles of
the jaw, and down to the chest, it seemed as if carefully dissected; the blue
veins and parotid glands shining through the cellular membrane. I in vain
looked for any opening, from which the fluid might come; the possibility of its
being derived from the left parotid, or of its being an encysted tumour, whose sac
had become condensed with the surrounding parts, at the same time occurred to
my mind; in either of which cases nothing more remained, than to close up the
wound, and to try what could be done by pressure. The cellular membrane in
the mesial line had become condensed, and formed the hardness felt in the neck;
it was therefore removed.

“ Having examined with attention a soft round body, of the size and colour of
a small lymphatic gland, partly embedded in the left submaxillary gland, I
observed a very minute puncture, as if from the point of a needle, and on gentle
pressure, a glairy fluid flowed from it. I immediately proceeded to separate the
gland from the surrounding parts, which at first was not difficult; but on getting
into the hollow of the jaw, it was more firmly attached, and the space was so nar-
row, that it was difficult to use the knife. A ligature was passed through the
gland, by which it was drawn out; but it was still difficult to tie the vessels
which bled. One very considerable vessel, (the lower maxillary,) was cut, the
bleeding from which was stopped by pressure made on the carotid; but it could not
be secured, until Lieut H., (who in the absence of another surgeon assisted,)
put his thumb into the mouth, and pushed the gland downwards, which greatly
assisted the rest of the operation. Then by passing a curved needle through the
parts several times, and cutting between the gland and the ligature, the whole
was removed, except a small process, which passed between the anterior belly
of the digastric and the mylo-hyoideus muscles, and probably joined the sublin-
gual gland; to this the actual cautery was applied.

“ The operation took up a considerable time, in consequence of the delay,
which took place before the gland was ascertained to be diseased, the faintness
which several times occurred from loss of blood and pain, and the necessity of
caution in cutting parts deep and out of easy reach. Four ligatures remained

Surgery, 495

on the vessels, the parts were carefully cleaned, and the edges brought together
by three ligatures and plaster; compresses and bandages were applied, and thirty
drops of laudanum given to the patient, who was put to rest.

“ 3l6'^. Did not sleep from the opium; but rested well in the night. Complains
of pain below the jaw. 01. Ricini ^ss. Cold water to the bandages.

“ April 6/A On the 2d had a purgative, which removed a slight degree of fever
which had come on; the tongue became clean, and his appetite returned. The
greater part of the wound has healed, and there is very little discharge. Slight
fulness at the lower part of the left side of the neck.

“ 10/A. Fulness has increased, the part is painful, and fluctuation is evident;
great anxiety is expressed regarding this, as the swelling originally commenced
on the same side; it, however, has now the character of an abscess. The wound
has healed, except at the ligatures, one of which, and the sutures have come
away. A poultice is applied to the swelling, and the diseased tooth extracted.

“ Wih. The cicatrix in the mouth has opened, and discharges matter, and a
probe passes one and a half inches down.

“ l^th. The swelling having pointed, it is opened, and some exceedingly offen-
sive pus, mixed with brown matter, is evacuated.

“The poultice was left off in a couple of days, and compresses were applied
over the cavity of the abscess, and the incision kept open by a tent. Under this
treatment, it healed rapidly; a little discharge from the opening in the mouth
continued some time longer. I did not see him again till the 27th, when he was
quite well; the cicatrix in his throat was very small, and did not disfigure him;
the opening into the mouth had healed, and a minute portion of saliva flowed
from the duct of the submaxillary gland, on the left side, probably from the sub-
lingual gland.” — Trans. Med. and Phys. Soc. Calcutta^ Vol. YlII. p. 1.

36. Suetin’s Immovable Fracture-apparatus. — Dr. Fricke of Hamburgh relates
in the Zeitscrift fur die g. Med. for April 1838, sixteen cases of Fracture suc-
cessfully treated by this apparatus. He waits until the swelling and inflam-
mation have subsided before applying the bandages.

37. Case of Extensive Aneurism by Anastomosis., in a child ten months old, in-
volving the branches of the Temporal and posterior Auricular Arteries, treated
successfully by the Twisted Suture. — A very interesting case of this is recorded
by Dr. J. Maclachlan in the Edinburgh Med. ^ Surg. Journ. for April last.
The subject of it was a remarkably fine, stout, healthy female twin child, who
was observed, a fortnight after birth, to have on the right temple a small red-
dish flat mark, not much larger than a pin-head. The discolouration slowly
spread, and gradually rose above the surface. When seen by Dr. M. in the
fifth month, there was in front of the right ear, immediately above the zygoma,
a tumour possessing the character of aneurism by anastomosis, extending up-
wards for about an inch, and being half an inch in breadth. There were several
small flat livid spots behind the ear and about the cartilages. In two months
the tumour had rapidly increased in every direction. It had ulcerated super-
ficially behind the ear, and there was a copious discharge of purulent matter
from the external meatus. Having attained certain dimensions, it appeared to
remain stationary. The parts behind the ear were, however, constantly break-
ing out into superficial ulcerated points, from which occasionally there was an
oozing of arterial blood. Compression upon the temporal artery was tried, but
for want of a proper apparatus, very ineffectually; and also the application of
ice and astringents, but as might have been expected without benefit.

On the 2d of April 1838, the child being then ten months old, the tumour
presented the following characters. “ It appeared to be chiefly arterial. A few
enlarged veins encircled and ran through it; but it seemed essentially to con-
sist in an enlargement in size, if not in number, of the branches of the super-
ficial temporal and posterior auricular arteries. Commencing at the root of the
zygomatic process, it proceeded directly upwards, reaching nearly the anterior
fontanelle, and terminating in a nuckle-like eminence. This, the temporal por-

496

Progress of the Medical Sciences,

tion, measured three inches and a half in length; at its origin it was rather more
than an inch in breadth, and, when distended, it rose throughout fully three-
fourths of an inch above the surface. The whole of the figured parts of the ear
were either of a livid or bright strawberry colour, little if at all elevated in
front, but in the angle behind forming a livid flaccid swelling. Immediately in
front of the mastoid process, this was of the size of a small filbert. From this
point it took a semicircular course backwards, following the direction of a super-
ficial branch of the posterior auricular artery, and extending upwards of two
inches. Towards the angle of the lower jaw there was a diffused subcutaneous
tumefaction of a bluish cast. The whole of the tumour, with this exception,
was of a deep strawberry colour, mammillated, brightening as it distended, and
with a bluish tinge here and there. The least exertion of crying produced a
remarkable increase in the temporal and occipital portions, and there was a con-
stant thrilling felt on applying the fingers to the temple. There were also two
detached, small, circular, flat naevi close upon the orbit, and two or three others
of the same nature above the ear on this side.”

At the date last mentioned Dr. M. introduced four needles. The first traversed
a space of an inch and a half in front of the ear, immediately above the zygoma,
“ the intention being, if practicable, to get under the root of the temporal artery.
No alteration, however, followed; on the contrary, the whole tumour became
enormously distended by the cries and efforts of the child. The second needle
was pushed through half an inch from the termination of this portion of the
tumour, so as to cut off any communication with the opposite side. The third
was introduced parallel with, and half an inch from, the first, this part having
enlarged considerably on twisting the thread round the first needle. The fourth
was inserted immediately in front of the mastoid process, close to the lobule of
the ear, embracing, apparently, the posterior auricular artery. This suture was
instantly followed by a most satisfactory diminution of the tumour occupying
the posterior part of the helix, as well as a change of colour in the concha and
meatus externus. The child was soon quieted; and in half an hour after it fell
into a sound sleep, interrupted momentarily by startings. Between three and
four o’clock it was up and lively. It slept sound during the night.

“ 4th April, Third day. — The child was seen regularly twice a-day since the
second, and did not appear to have suffered the least inconvenience from the
needles. The temporal portion of tumour appeared to be more flaccid, and of a
deeper blue. The mastoideal and occipital portions were stationary. The child’s
health was undisturbed, and the needles were firm.

“ 6th April, Fifth day. — The needle behind the ear was removed to-day, there
being slight discharge from the punctures, with surrounding excoriation, the
tumefied parts overlapping and being irritated by it. The remainder were firm.
In the neighbourhood of excoriation were several hard nodules, occasioned by
effused fibrin, and resembling an external haemorrhoid. The posterior part of the
ear, as also the meatus, were already much reduced. Four more needles were
introduced, the situation of which are pointed out in the accompanying plate.
On this occasion, waxed thick purse-silk was employed, as being less likely to
cut the skin. Several turns of the silk were made over the parts isolated by
the needles, by crossing it from one needle to the other. The child cried less,
and fell into a sound sleep soon after the operation.

“ 7th April, Sixth day. — Health continued undisturbed. The first and third
needles introduced on the second were withdrawn to-day, though firmly fixed.
A drop of blood followed the removal of the first. The silk has been allowed
to remain. Excoriation behind much deeper. — A weak solution of the sulphate
of zinc to be applied.

“ 8th April, Seventh day. — The temporal portion of tumour was less red.
The part anterior to the ear was firm, semitransparent, and of a very pale-blue
colour, evidently resulting from effused fibrin. The remaining needle was intro-
duced on the 2d. The one near the termination of the temporal portion, the
second inserted, was removed to-day. Neither discharge nor ulceration had

Surgery, 497

taken place at either of the points. The child has been lively and in high
spirits. Excoriation discharging copiously, but not extending.

“11th, The remaining needles were removed, and found slightly oxidized.
Behind the ear ulceration is rather deeper, and yesterday the discharge was
discoloured with blood. From the surface of the tumour, immediately above
the zygoma, issued a slight sanious and purulent discharge, but the parts under-
neath felt firm. On withdrawing the seventh needle, a drop of scarlet blood
followed. The parts embraced by the silk are white, but not ulcerated.

“ The child was daily visited since last report. Its health continued undis-
turbed, and there appeared to be a decrease in the whole tumour operated upon;
at all events, it was not nearly so much elevated when the child cries, nor is it
so bright.

“ 13th, Discharge from ulcerated parts was much increased, and the tract of
the first needle in front of the ear was deeper. The whole tumour above this
was also superficially ulcerated and discharging thin ichor. The subjacent
parts continued firm, and, excepting when the tumour is touched, the child
appeared to be free from pain.

“ In rather less than three weeks from this date the ulcerations had healed
under common applications, the solution of the sulphate of zinc, or the white
oxide of zinc ointment. The tumour gradually disappeared, leaving a firm fibrous
texture of a whitish colour indented with the tract of the needles, and very closely
resembling a superficial burn. That portion behind the ear of a crescentic form,
retained for some time its brightness. I was desirous of passing under and
through h two or three needles; but the mother, who all along appeared to view
the measure adopted as an experiment, offered so many objections that my in-
tention was not carried into effect. This I scarcely regret. At the period I am
writing (30th November, 1838,) the skin had nearly acquired its natural colour,
interspersed only in front and behind the ear with some little red points. The
previous extent of the tumour could now' hardly be traced, the hair is growing
over it, and, as the child advances in years, that portion only in front of the ear
will be exposed. There is still a small flaccid livid swelling, rather larger than
a pea, in the loose integuments in front of the mastoid process, not, how'ever,
under the influence of the circulation; and the mother says it is decreasing.

“ It would be difficult to find a more satisfactory or successful case than the
above. In this instance, at least, Lallemand’s method effected all that could be
desired. It is obvious that no other could have been attended with so little
risk. Excision w'as out of the question; the boldest operator, and the most
dexterous dissector, would scarcely have attempted the knife. Ligature of the
carotid artery was a measure uncertain in result. Although Mr. Travers suc-
ceeded by tying the carotid in a case of aneurism by anastomosis in the orbit,
the very free inosculation in the scalp appears to be unfavourable when the tu-
mour is situated there; and it has been remarked by Mr. Phillips,* ‘ that liga-
ture of the carotid has never succeeded in one of the cases in which it has been
employed by Pelletan, Mussey, and Wilhaume, for the cure of erectile tumours
affecting the temporal fossa. The case related by Dr. Mussey, in the American
Journal of Medical Sciences, February 1830, in which he tied both primitive
carotids for a large aneurism by anastomosis, on the vertex, and had in six
weeks after to extirpate the tumour, is not in favour of the ligature. In a case
operated upon by Dupuytren also, in which he tied the carotid for a large naevus
situated about the ear, and including the whole texture of the surrounding parts,
the operation was equally unsuccessful. It appears to be more certain in cylin-
droid dilatation of the arteries. Mr. Syme and others have recorded cases in
which they succeeded; but, as it is observed by Lawrence, ‘ tying the arteries,
or the main trunks of the vessels which supply the part of the body in which
naevi are situated, cannot according to our present experience, be much relied
on.’ Extirpation and ligature of the carotid being rejected, the only remaining
method that appeared at all applicable was that proposed and executed by Mr.

* London Med. Gaz. Vol. xii.

42^

498

Progress of the Medical Sciences,

Fawdington of Manchester, the seton; but the purely arterial nature of the tu-
mour seemed to render it hazardous, and the needles were employed, as being
less likely to be followed by haemorrhage.

“ A remarkable circumstance in the history of this case is, that very few
needles, eight only, were sufficient to obliterate the tumour. The repeated
ulcerations behind the ear seemed to be an effort of nature to destroy the dis-
ease, requiring only a little assistance from art to perfect the cure. Another
point worthy of remark, was the total absence of constitutional irritation from
the needles. Aware of the danger of punctured wounds in the scalp, I was
rather apprehensive of an attack of erysipelas; and, as the needle behind the ear
must have embraced some branches of the portio dura, there were grounds for
anticipating other disagreeable consequences. However, no constitutional effect
whatever followed the insertion of the needles on either days. The operation
was completed without the loss of a single drop of blood; and the tumour was
removed with little or no deformity. These, then, appear to be the principal
advantages of the treatment of aneurism by anastomosis, or nsevi, by the twisted
suture; viz: simplicity; little or no pain in its performance; little or no consti-
tutional disturbance; little deformity, perhaps less, if necessary, except the
seton, than by any other method; and little or no risk of haemorrhage. On this
last point Lallemand remarks, ‘ the fear of haemorrhage is groundless. Imme-
diately after the needle is introduced it fills the wound it has made, and in a
very short time inflammation changes the nature of the surfaces divided, and
haemorrhage becomes impossible.’

“ I employed fine darning needles, previously prepared with wax-heads, to
handle them by. Although Lallemand appears to have used needles, he re-
commends pins, such as are used for transfixing insects, as being more easily
cut or broken off than sewing-needles. He considers thread unnecessary; —
‘ it prolongs the operation, does not increase the inflammation, nor is it neces-
sary to prevent haemorrhage.’ It appears to me, however, to assist the progress
of the cure; by compressing the vessels, it induces adhesive inflammation in
their sides; they are more readily obliterated, and the nature of the tumour is
essentially changed, though the irritation occasioned by the presence of the
needles seems to be the chief source of benefit.

“ Successful, however, as the twisted suture has been in the case of naBvi and
aneurism by anastomosis, like every other method employed, it has occasionally
failed. In two cases seen by M. Bouchacourt, the twisted suture practised
twice was without benefit; yet it is well deserving a trial. In a considerable
majority it will be found to answer; and it is less objectionable than most plans.”

OPHTHALMOLOGY.

38. On Injuries of the Eye hy Percussion Caps. By Samuel Crompton, Esq. —
The following observations were made in the practice of Mr. Barton, surgeon
to the Manchester Eye Institution, to whom I am indebted for permission to
publish the illustrative cases, and his method of treating them.

One of the fragments, into whcih a percussion cap breaks when it is exploded,
sometimes enters the eye. The accident generally occurs in shooting with, or
in discharging, percussion caps with a hammer. I have seen many instances
of it, and have preserved notes of seven cases, in each of which the injured eye
was destroyed. In one of these cases the vision of the other eye, also, was
nearly lost, from sympathetic inflammation; and it is most likely that, there
would have been a similar termination of the rest, if that treatment, which I
shall presently describe, had not been adopted. The peculiarities and impor-
tance of these injuries, and the consideration that they are unnoticed by syste-
matic writers on the eye, have induced me to detail, more minutely than would
have otherwise seemed necessary, the most remarkable circumstances relating
to them.

Ophthalmology, 499

In every case the fragment of cap was driven into the posterior chamber of
the eye; but immediately after the accident, the changes produced in the eye,
and the symptoms, were so like those observable in penetrating wounds of that
organ, when no foreign body remains in it, that it was impossible to ascertain,
at first, whether the cap was in the eye or not. The wound made by the
entrance of the fragment of cap into the eyeball was generally a clean incised
one, and healed readily. The vision was not destroyed immediately in those
cases in which the cap went through the sclerotica, and did not injure the trans-
parent parts of the eye. For a length of time, varying from a few days to a
month after the accident, the patients appeared to be in a fair way for immediate
recovery; but at the expiration of that time they were suddenly seized with
most acute pain in the eye, attended with extensive chemosis, and with haziness
of the cornea in some of the cases. Suppuration never happened. The pain
subsided entirely for a while, or was greatly mitigated in a day or two after its
commencement; but this cessation was only temporary, for it always recurred
and subsided at uncertain periods, until the vision with the injured eye was
entirely destroyed, the eyeball in a state of painful chronic inflammation, and
the health of the patients much injured by the irritation occasioned by the injury,
and from anxiety for their sight; for the vision of the other eye became affected
at this stage of the disease, by the inflammation extending to it by sympathy.
The first indications of its commencement there, were a slight redness of the
conjunctiva, and an inability to see so well as formerly with the eye, or to bear
the ordinary light of a room without pain and confusion of vision.

In case I. the effects of the sympathetic inflammation were, a dull yellow
colour of the sclerotica, a change in the colour of the iris, and adhesion of it to
the capsule of the lens; and a very irregular and small pupil, filled with a dot
of opaque capsule.

The fragments of caps taken from the eye, after being within it for months,
were only tarnished; they bore no appearances of undergoing changes similar
to those which take place in pieces of steel during their exposure to the humours
of the eye; they were always of a considerable size, and their angles were sharp.
Mr. Barton believes that the sympathetic inflammation in these cases is occa-
sioned by the presence of a fragment of cap in the other eye, and that the only
means of preventing it, or of allaying it when it has arisen, is the removal of
that fragment from the eye. He has treated many cases on this principle; of
seven of which I have preserved the' following notes.

Case 1. — W. , Esq., about forty years of age, and of very intemperate

habits, was shooting on the moors in August, 183*2, when, on discharging his
gun, something cut his right eye. He lived far from Manchester, and was under
the care of his usual medical attendant, who used active measures to subdue
the pain and inflammation which occurred in a few days after the accident. He
consulted Mr. Barton, for the first time, on the 29th October, 1833, when he
had continued pain in his right eye, occasionally so severe as to prevent him
sleeping for successive nights; his vision with it was destroyed; the left eye
also was inflamed sympathetically, and vision with it so much impaired that
he could not find his way. His health had suffered greatly from the effects of
the disease, and his anxiety for the recovery of his sight. Mr. Barton told him
that it was very probable that something had entered the eye and occasioned his
sufferings; but, in compliance with the request of the patient, who was unwilling
to submit to an operation for its removal, various plans of medical treatment
were tried until the 3d of November, without the least benefit being derived
from them. On this day a large piece of the cornea of the left eye was cutaway,
in order to remove the foreign body; but the eye was so exquisitely sensitive,
that attempts were not made to find it. A large poultice was applied to the
lids. In a few days afterwards a large fragment of a percussion cap was removed
from the coagulum, which filled up the opening that had been made in the globe
of the eye; it was merely tarnished, and its angles and margins were as sharp
as if it had been just broken. The patient was permanently relieved, but the
sympathetic inflammation had produced so great changes in the other eye, that
it was necessary to perform an operation for artificial pupil upon it.

500

Progress of the Medical Sciences.

Case 2. — George Ankers, of Staly-Bridge, about S8 years of age, on the 29th
January was sitting near a man who discharged a gun, when a portion of cap
entered his right eye. On the following day he could see across a room with
that eye, but in the course of a month vision with it was quite lost. On the 8th
April, the conjunctiva was very vascular, and the eye occasionally very painful.
He could not bear the ordinary light of a room without placing his hand over
the other eye (the left), neither could he read more than one, two, or three lines
with it, before the letters became indistinct, and the eye painful. A flap of the
cornea of the right eye- was removed, and a poultice was applied to the eyelids.
On the 16th of June, a friend removed the fragment of cap from the cicatrix in
the front of the eye-ball. He has been easy since, and the powers of the other
eye are quite restored.

Case 3. — Master R., of Stockport, about six years of age, was playing, on
the 25th of July, 1836, with a boy who was exploding percussion caps with a
hammer, when a fragment of one cut his eye. This eye was so free from pain
and inflammation for several weeks, that it was hoped that the cap had not
^entered it; but by the 21st of September it had assumed the appearances indi-
cative of its presence there. A portion of the front of the eye-ball was cut away.
On the following morning the fragment of cap was found in the poultice which
had been applied to the eye-fids; it had only become of a darker colour by being
in the eye.

The following cases were treated as the above: —

Case 4. — W. Williamson, of Stockport, injured in shooting.

Case 5. — 'Adam Chamley, of Hebden Bridge, Yorkshire, injured in shooting.

Case 6. — Mr. T., of Cumberland, injured in shooting.

Case 7. — John Taylor, of Manchester, injured whilst standing near a man
exploding a percussion cap with a hammer.

The details of the four last cases are so like those of the three first, that it
seems unnecessary to give them. In all, however, the object of the operation
was gained; the sympathetic inflammation being suspended in the first case, and
the symptoms which were thought to indicate its approach being removed in
the others. The operation is thus performed: — The patient being placed in a
convenient position, the operator forms, by means of Beer’s knife, a large flap of
the cornea, which he seizes with the forceps and cuts away with a pair of curved
scissors. A dose of laudanum is then administered to the patient, and a linseed-
meal poultice applied to his eye-lids. The operation always gives great pain,
and should be performed as rapidly as possible. The eye is so exceedingly
sensitive, that attempts to find the fragment of cap cannot be endured. In all
the cases of Mr. Barton, the cap was found in the poultice, or in the coagulum
which closed the opening into the eye, in a day or two, or at a longer period
after the operation.

I have made diligent inquiries as to whether the caps which inflicted the
injury were grooved or smooth. I believe that they were generally smooth and
of an inferior kind, called French caps; but it is very likely that both kinds are
very dangerous when exploded between two flat surfaces on a level with the eye;
an amusement with children which is very common in this part of the kingdom.
London Medical Gazette, Oct. 28, 1837.

39. Iris Sympathetica, By Mr. Mackenzie, (extracted from a clinical lecture.)
1. The injuries which, affecting one eye, are most apt to excite, after sometime,
sympathetic inflammation in the other, are penetrating wounds, inflicted^by cutting
instruments, or by the forcible projection of splinters of iron or stone, or the
fragments of percussion caps. A mere blow on the one eye (for example, with
a stick) has been known to impair the other sympathetically; but in general it is
from penetrating wounds that the disease we are now considering takes its rise.
Sometimes the wound is inflicted by such an instrument as a chisel or screw-
driver, as was the case with Finlay, so that there can be no suspicion of any
thing being lodged within the eye; while, in other instances, the suspicion is
strong, or there is an absolute certainty, that a foreign body has passed through

Ophthalmology. 601

the tunics, and lies there unextracted. Sympathetic iritis has been known to
occur both where the foreign body has been extracted immediately after the
receipt of the injury, and where it has lain for weeks within the eye.

The injuries we are now speaking of are sudden and violent. They are gene-
rally attended by a loss of part of the humours, and by an extravasation of
blood into the interior of the eye. The parts divided have generally been the
cornea and iris, with a small part of the sclerotica and choroid. The junction,
in fact, of the cornea and sclerotica, and CQnsequently the annulus albidus of the
choroid, is the place which has been wounded in most of the cases which I
have seen. I think sympathetic iritis is more apt to be excited if the wound
has been followed by a protrusion of the iris, and such a cicatrice of the cornea
and sclerotica as keeps the portion of the iris not involved perpetually on the
stretch. If the wound has been so extensive as to divide or lacerate the retina,
sympathetic inflammation is probably still more apt to occur, the injury which
the lens suffers in such cases, and the traumatic cataract which follows, have
little or no influence in causing sympathetic disease. A wound which impli-
cates merely the cornea and lens, or even a wound of the cornea, with simple
prolapsus iridis, is not apt to excite sympathetic iritis. I have never known,
any of the operations for cataract bring on this affection; not even when, after
that of extraction, the iris protruded, and the cicatrice which followed caused
dragging of the opposite side of the iris, have I ever seen sympathetic inflam-
mation. These facts, then, would lead us to conclude that injuries of that part
of the choroid called the annulus albidus are most apt to cause sympathetic
iritis. If, along with a wound of that part of the choroid, there is a loss of part
of the vitreous humour, and a protrusion of the iris, I should dread an attack of
sympathetic inflammation; especially if, about the time of the cicatrization of
the wound, the patient began to use the good eye in earnest, committed any
irregularity in diet, over fatigued himself, or suffered from mental excitement or
distress.

II. — Were we to judge of the period of time which generally elapses between
an injury of one eye and sympathetic inflammation manifesting itself in the other,
from the six cases which I related formerly, as having occurred in the practice
of this infirmary, we should say that five weeks was the most frequent period;
for in Mill, the sympathetic disease came on six weeks after the injury; in
Paterson, the period was three months; in Moore, one month; in Downie, five
weeks; in Finlay, five weeks; in Gartshore, four or five weeks. In three out of
the six cases recorded by Mr. Lawrence, the period is not mentioned; in the
other three, the periods were a few weeks, five years, and soon after six weeks.
In Mr. Wardrop’s two cases the periods were three weeks, and one year.

III. — The subjects of sympathetic iritis have most frequently been, in my
experience, men employed in iron-works. At the time when their eyes were
injured, their general strength was not impaired, but from their habits of life,
and especially from their liberal use of spirits and tobacco, their constitutions
were in an artificial state, very unfavourable for throwing off any inflammatory
disease. Hence it appeared to be, that the iritis degenerated into the arthritic
variety, and proved so intractable^ In some of the cases I have seen the sym-
pathetic inflammation was modified by scrofula, a modification scarcely less
troublesome than the arthritic. In one of our cases. Dr. Kennedy observed that
the wounds made in bleeding the patient at the bend of the arm generally sup-
purated; which led him to inquire whether a syphilitic taint might not be present.
The patient acknowledged having had some primary syphilitic symptoms before
he received the injury of his eye; but he had no sore-throat nor eruption, and
the eye, sympathetically inflamed, showed no peculiar indications of syphilis.

IV. — It sometimes happens that the patient is unable to specify any exciting
causes for the sympathetic attack; but, in other instances, causes of this kind
are distinctly mentioned. For example, in Finlay, the exciting cause was
manifestly the reading, for three or four hours together, in a book printed in a
small type, and in one of Mr. Lawrence’s cases, the eye had been incautiously
worked. The wounds of the eye, which are apt to give rise to sympathetio

502 Progress of the Medical Sciences,

iritis, commonly take from a month to six weeks to cicatrize. Whenever they
,are healed, the patients are apt to re-commence their usual employments and
modes of life; and then it is that the exciting causes of the sympathetic disease
come into play. The same sort of exciting causes which produce the first attack
of sympathetic inflammation, also bring on relapses when the patient is recover-
ing; and it is generally by a succession of relapses that vision is ultimately
destroyed.

V. — The local symptoms of sympathetic ophthalmia are those of iritis, passing
rapidly into amaurosis and atrophy of the eye. Not unfrequently the first symp-
tom is dimness of sight. This is rapidly followed by zonular redness around
the cornea, dingy greenness of the iris, flexibility of the cornea, bogginess of
the sclerotica, opacity of the capsule, greenishness of the lens, varicosity of
the rectal vessels, the presence of red vessels ramifying over the surface of the
iris, contraction and adhesion of the pupil, puckering and bolstering forwards of
the iris, and total insensibility of the retina. The pain is very variable; for in
some it is slight, as in Gartshore, who said she had had no pain in the eye sym-
pathetically affected, while in others it is severe, as in Finlay. Photopsia is a
usual symptom about the commencement of the attack. In some there is great
intolerance of light, as in Paterson; in others, there is little. At length, the ,
shrinking of the eye-ball, and especially of the cornea, is very remarkable. In
one of Mr. Lawrence’s cases, both cornea had shrunk to the size and figure of
a barleycorn placed horizontally.

There can be no doubt that retinitis forms a part, and a, chief part, in all cases
of sympathetic ophthalmia. Perhaps retinitis occurs first, and added to it is
the iritis. The early loss of vision shows that the retina is deeply implicated
from the very commencement. The flexibility of the cornea, and softness of
the sclerotica, indicate the vitreous fluid to be lessened in quantity. The
changes which are visible in the capsule and in the iris are plain indications
how far these textures are affected.

Sympathetic iritis is generally an inflammation of that description which is
called unhealthy. It sometimes resembles scrofulous internal ophthalmia; more
frequently it resembles what the Germans call arthritic ophthalmia. The symp-
toms are often such, that one skilled in German ophthalmology would at once
say, here is arthritic iritis. I have often observed to you, that if we use the
term arthritic merely as a conventional one, to express a certain variety of eye
disease, characterized by certain signs, this may be allowed; but if by arthritic
is meant strictly gouty ^ applied to the cases we are now considering the term is
incorrect. The subjects of sympathetic iritis may have some peculiarity of
constitution, produced by their mode of life, and by the nature of the ingesta to
which they have habituated themselves; but these are not sufficient grounds, I
think, to suppose that they are labouring under the gouty diathesis. It is more
probable that the particular textures of the eye which are affected, and the modes
in which these textures are suffering, produce the peculiar symptoms which
present themselves so strikingly in such cases, and which the Germans choose
to call arthritic.

Amongst the constitutional symptoms we may mention quickness of the pulse,
thirst, a marked buflfy coat on the blood drawn from a vein, a pallid complexion,
and obstinate constipation. A degree of ill health, in fact, has generally resulted
from the confinement, want of exercise, and medical treatment necessary for the
cure of the original accident; and in this debilitated state the patient is attacked
by the sympathetic disease.

VI. The fact, that disease in one eye is apt -to be followed by similar disease
in the other, has long attracted attention. Inflammation, cataract, and amaurosis,
have especially been observed to occur in this way, from what is termed a con-
sensus, oculorum,

Mary Young (No. 8266), who is at present attending as an out-patient,
presents a curious instance of inflammation passing from one .eye to the other.
Several years ago she was affected with trichiasis, xeroma of the palpebral con-
junctiva, and thickening and opacity of the left cornea. At that time the right

503

Ophthalmology.

eye was perfectly well; but within these few months we have the same set of
symptoms in the right eye, only in a less degree, which we had formerly in the
left. The corresponding eyelashes are inverted, the corresponding part of the
conjunctiva has become dry, and the corresponding portion of the cornea is
opaque.

Jess Gemmel (No. 6234), and John M’Brair (No. 8561), two patients at
present on our list, afford instances of sympathetic amaurosis, and oscillation
of the eye-ball. In Gemmel the left eye was destroyed by a blow and eight
days after the right eye was found affected with oscillation, and a great degree
of dimness of sight, but without inflammation. We know less of M’Brair’s
history, as the injury which destroyed the sight of his left eye, and produced
almost a complete absorption of the iris, occurred in childhood; but in him we
have another example of sympathetic oscillation and amaurosis.

Dr. Albers (Himley and Schmidt’s Ophthalmologische Bibliothek, ii. Band,
iii. Stuck, p. 169,) relates the case of a countryman, who, in a scuffle with his
brother, was struck with a pitchfork in the right e}'^e, w^hereby the cornea and
iris were seriously injured. The wound healed up in such a way that the sight
was not entirely lost. In three days after the inj..ry, the patient observed a
diminution in the vision of the left eye, and a distinct opacity in the pupil was
discernible. This increased so rapidly, that in eight days there were all the
signs of a fully formed cataract. Half a year afterwards he was operated on
by Professor Jung, of Marburgh, but unsuccessfully, the patient remaining com-
pletely blind. Albers asks, if this case does not go to prove a decussation of
the optic nerves; to which Himley replies in the negative. For suppose (says
he) that the cataract, the sudden formation of which is very remarkable, was
really a consequence of the injury, and not only so, but that the injury was the
sole cause of the cataract, and did not operate merely in exciting a tendency
already existing to opacity, we find similar appearances of consensus frequently
in the corresponding teeth of the twm sides, where no such decussation or nervous
communication can be brought forward in explanation.

Notwithstanding this objection of Himley, it is generally acknowledged that
those organs of the body are most apt to affect others, or in their turn to be
affected sympathetically, in which the nervous system is the most developed;
that there are no organs between which a sympathy in different states of disease
exists so remarkably as the two eyes; and that there are no organs in which the
nervous system is more developed, none in which the nerves of the opposite
sides are connected in the same intimate way.

In the cases which we have been particularly considering, it is not improbable
that the blood-vessels on the side of the injured eye, being in the state of fulness
and inordinate action which attends inflammation, communicate to those of the
opposite side, with which they have connections within the cranium, a disposi-
tion to the same morbid state in which they themselves are. The ciliary nerves,
also, of the injured eye may be the means of conveying into the third and fifth
nerves an irritation, which may be reflected from the brain to the same nerves
on the opposite side. I think, however, that the chief medium through which
sympathetic ophthalmia is excited, is the union of the optic nerves. The
researches of modern anatomists have tended only to confirm the conjectures of
Newton (Opticks, query 15,) that the optic nerve of the one eye proceeding
backwards, and meeting the optic nerve of the other eye, the two mingle their
fibres, and partially decussate. It is extremely probable that the retina of the
injured eye is in a state of inflammation, which is propagated along the corres-
ponding optic nerve to the chiasma, and that thence the inflammatory action is
reflected to the retina of the opposite eye, along its optic nerve.

VII. The history of the case will, in general, be sufficient to prevent any diffi-
culty in the diagnosis. Sympathetic ophthalmia may be complicated with
scrofula, and assume a good deal of the scrofulous character; or it may be
complicated with syphilis, which an examination of the patient’s skin and throat,
and an inquiry into his previous health, will serve to elucidate. These compli-

604

Progress of the Medical Sciences.

cations, as well as the arthritic, will no doubt render the symptoms more severe;
but they will scarcely influence the line of treatment to be followed.

VIII. The prognosis is so unfavourable, that it is our duty to guard the patient
who has suflfered an injury of one eye, against the exciting causes of sympathetic
iritis, from the very first. When this disease is actually present, even the most
active treatment is generally ineffectual. Indeed, I have never seen an eye
recover from sympathetic iritis. Renewed attacks have, in every case, terminated
in extinguishing vision. Mill is the only exception; but in him we cannot cal-
culate yet on the final result. Any of the exciting causes I have enumerated
would again rouse in him an inflammation, which all our applications might
fail to check.

IX. Rest, antiphlogistic means, and the use of mercury, are the principal
points of the treatment in sympathetic ophthalmia. These means, we have
abundant proof, are not very successful. Still, to relinquish these remedies
would be wrong.

There is a disease, Mr. Wardrop informs us, frequent in the eye of the horse,
having the appearance of a specific inflammation, which usually first affects one
eye and then the other, and almost always sooner or later destroys vision. It is
known among some farriers, that, if the eye first affected with this disease sup-
purates and sinks in the orbit, the disease does not attack the other eye, or sub-
sides, if it had commenced in it. Thus they have adopted a practice of destroying
altogether the diseased eye, in order to save the other; which is rudely done by
putting lime between the eyelids, or thrusting a nail into the cavity of the eye-
ball, so as to excite violent inflammation and suppuration. Mr. Wardrop has
frequently succeeded in saving one eye of the horse by adopting this practice;
but he destroyed the eye by making an incision in the cornea, and discharging
through it the lens and vitreous humour. “ In some diseases of the human eye,”
says he, “ where the disease makes a similar progress, first affecting one eye
and then the other with complete blindness the practice so successful in animals
might, by judicious discrimination, be beneficially adopted.” — (Morbid Anatomy
of the Human Eye, vol. ii. p. 139.)

The practice thus hinted at by Mr. Wardrop has actually been adopted,
though with a somewhat different view, by Mr. Barton of Manchester, in cases
of injury of one eye with the fragment of a percussion-cap.*

In the cases published by Mr. Crompton this^ practice appears to have not
only relieved the patients of the pain they were suffering in the injured eye, but
to have arrested the sympathetic inflammation which threatened the other. Is
not this, then, good ground to adopt a similar plan, not only in cases where we
have reason to suppose that some foreign body is lodged within the eye, but
even in other cases, where the one eye being disorganized, and deprived of sight,
the vision of the other eye seems likely to be lost by sympathetic inflammation!
Where there is a suspicion of some foreign body being within the injured eye,
there can be no question that Mr. Barton’s practice ought to be adopted; but
even in other cases, w'hy should we hesitate to lay open an eye in which vision
is extinguished, if the operation affords as I think it does, a hope of our being
thereby able to save the other. — Lond. Med. Gaz. Oct. 1838.

MEDICAL JURISPRUDENCE AND TOXICOLOGY.

40. Child at Birth of Enormous Size. — The average weight of a child at birth
is usually considered to be from seven to eight pounds. Dr. Dewees met with
two cases in which the weight was fifteen pounds {System of Midw.)\ and Dr.
Francis says that an instance occurred in New York, where the foetus (born
dead) weighed sixteen pounds and a half. {New York Med. §r Ehys. Journ. II.
p. 20. 1823.) An example of a still greater weight in a newborn child is related

* See preceding article. Ed.

505

Medical Jurisprudence and Toxicology.

in a recent number of the Lancet (22d Dec. 1838) by Mr. J. D. Owens. The
child was born dead after a labour of sixteen hours’ duration. Its weight and
admeasurement are given as follows: — “The long diameter from the occiput to
the root of the nose, inches; the occipito and mental, 8| inches; from the
parietal protuberances, 5 inches; the circumference of the skull, 15j inches; the
circumference of the thorax over the xyphoid cartilage, 14J inches; the breadth
of the shoulders, 7i inches; the extreme length, 24 inches. The weight seven-
teen pounds twelve ounces. We supposed that this was the largest foetus on
record; hut on referring to Dr. Beck’s learned work on Med. .Turisprudence,
sixth edition, p. 276, we find that he quotes Cranzius as saying that “he had
seen one foetus weighing twenty-three, and another twenty-seven pounds!!”

41. On the manner in which death is produced hy Carbonic Acid Gas. — Dr. Gold-
ing Bird, communicated to the Physical Society of Guy’s Hospital, at their
meeting, 23d February, 1839, some interesting views relative to the pathology of
death from charcoal vapour, illustrated by experiments.* Restated that he did
not wish to enter at length into the question of the mode in which carbonic acid
produces death — whether, as supposed hy Brodie, Bichat, Nysten, &c., by
excluding oxygen, or, as believed by Christison, Collard, Pyl, &c., by acting
as a specific poison — as this would occupy too much of the society’s time; hut,
from all the investigations he had made, he was led to agree in every respect
with M. Collard de Martigny in believing that carbonic acid, when sufficiently
diluted to enter the air-passages, acts as a specific poison, and produces its fatal
effects, notwiffistanding that sufficient oxygen may he present in the air of the
apartment to support animal W^e per se — a statement fully borne out by the very
frequent occurrence of fiorid blood in the hearts, lungs, and brains of persons
who have died from inhaling an atmosphere vitiated by carbonic acid gas. This
fact, although somewhat opposed to the orthodox and popular opinions as given
in most of our works on toxicology, is, nevertheless, fully supported hy the
cases which have been published in the continental and British journals. The
arguments in favour of this view of the specific action of carbonic acid adduced
by Dr. Bird, were unfortunately too extended to be comprised in our limited
space: this we regret the less, as we understand the matter will be fully treated
of in the next number of Guy’s Hospital Reports.

From a review of cases of death resulting from the inhalation of air con-
taminated by the presence of carbonic acid, we are compelled to modify the
opinions imbibed from the perusal of most toxicological works; for it is no less
certain than true that the great majority of the pathological appearances attri-
buted to death by the inhalation of charcoal vapour, are as frequently absent as
present. The reason of the diversity observed in the post-mortem appearances
of persons killed by apparently one and the same cause, and under circumstan-
ces apparently in every way identical, is at present involved in obscurity; much,
probably, may depend upon the degree of vitiation of the air of the room; more,
perhaps, on the age, health, and tenr.perament of the individual exposed.

Dr. Bird’s observations lead him to believe that an atmosphere containing 10
per cent, of carbonic acid will quickly produce death; in birds this occurred
after they had respired it from seven to ten minutes: and that the presence of 5
per cent, will prove no less certainly fatal, although requiring a longer time for
the production of that effect — in birds about half an hour. A bird of the same
size as the above lived an hour and a quarter in a vessel containing the same
bulk of atmospheric air, and, upon removal from it, revived completely.

It is difficult, from the imperfect manner in which cases are too generally
reported, to represent the comparative frequency of the occurrence of particular
post-mortem appearances by numbers; but the following numerical statement,
drawn from the best reported cases in the German medical journals, including
two from private sources, <*and of late occurrence, would, perhaps, be of service
to the medical witness, if it did no more than point out to him the fallacies into

* Since published in Guy’s Hospital Reports, for April, 1839.

No. XLVIIl. — August, 1839. 43

506

Progress of the Medical Sciences.

which he would be likely to be betrayed by trusting to the generally received
and popular opinions of the pathological effects which ought to result from the
inhalation of carbonic acid: —

External Phenomena.

14 cases examined Preceded death i

12 cases
11 cases

6 cases

7 cases
1 4 cases

18 cases
18 cases
7 cases
18 cases

7 cases
13 eases
13 cases

18 cases

7 cases
10 cases

in -

^Vomiting had not preceded death in
CFace bloated and livid

C pale and natural

C Froth before mouth and nostrils

C ^’-absent - - .

C Eyes injected - - -

\ natural - - -

C Limbs remarkably rigid
\ flexible -

Abdomen tumid -
distended

^ Abdomen

5
9

6
6

6
2

5
2

Internal Phenomena. — Head.

C Serous effusion in ventricles and under arachnoid 15

I absent ----- 3

C Extravasation of blood - - - - 3

I none ----- 15

C Blood black in the brain - - - - 3

florid ------ 4

C Membranes turgid with blood - - - 14

I natural - - - - - 4

Chest.

C Mucous membrane of larynx and pharynx injected

C healthy

c Lungs distended ------

2 collapsed ------

c black or deep violet - - - -

red or pale - - - - -

f Blood only in right ventricle of right

in both ventricles - - - -

in neither ------

C in heart black - - - - -

2 florid -----

coagulated

fluid

The only phenomena to which he had found, as yet, no exceptions are —

A. The presence of livid spots over the whole body; often, however, not more
intense than occur from other causes.

B. Tongue exserted and generally grasped between the teeth, unless vomit-
ing has preceded death, when the tongue is found concealed by the teeth.

C. Intensely calm and sleep-like aspect of the corpse, whether pale or
bloated.

D. Congestion of the cerebral vessels amounting to apoplexy, often attended
by copious serous effusion into the ventricles, under the arachnoid, or at the
base.

In conclusion, he offered the following conclusions as fairly deducible from
the result of these investigations: —

1. That carbonic acid sufficiently diluted, as in charcoal vapour, does not act
fatally by closing the glottis nor by excluding oxygen, but by a specifically poi-
sonous action.

Midwifery. 507

2. That carbonic acid thus diluted may produce death, although a proportion
of oxygen, sufficient se to support life, may be present in the air of the
apartment; and on this account no dependence can be placed on the florid colour
of the blood in the lungs, as evidence against carbonic acid gas having been the
cause of death.

3. That such a vitiated atmosphere acts most probably primarily on the ner-
vous system; and secondarily, but by no means essentially or necessarily, upon
the circulating fluid.

4. That the death of persons inhaling an atmosphere vitiated by carbonic
acid is produced by apoplexy.

5. That no dependence can be placed upon the bloated and red, or pale and
contracted features; on the liquidity or coagulated state of the blood; on the
injection or paleness of the mucous membrane of the air-passages or intestinal
tube, as positive evidence for or against the action of carbonic acid gas as a
cause of death, in medico-legal investigations.

MIDWIFERY.

42. Cartilaginous condition of the Neck of the Uterus — Incision of this part to
facilitate delivery. — Dr. Burdach of Finsterwalde, was called June 27th, to a
woman twenty-eight years of age, pregnant with her first child, and who had
been attacked three days previously (June 24th,) with labour pains; the mem-
branes had broken during that day. The midwife could not reach the neck of
the uterus, and although the pains continued, the labour had not advanced by
the 26th. Borax was then given in doses of six grains to increase uterine con-
tractions, but though the medicine produced this effect, labour was not advanced.
Dr. B. found the anterior lip of the neck of the uterus hard and callous. He
prescribed emollient fumigations and an opiate ointment, which were con-
tinued until the next day (June 28) without any advantage. He then made
an incision an inch and a half long in the anterior lip; but little blood flowed.
Borax eight grains with one grain of musk to increase uterine efforts was given
in repeated doses. But labour advanced so slowly that the forceps were resorted
to and a dead infant delivered. The incision was not torn, the wound healed
promptly and the patient entirely recovered. — Revue Med. Dec. 1838, from
Medizinische Zeitung.

43. Prolapsus of the Uterus — Incision into the Neck of the Organ — Cure. — By
Dr. Gruhn, of Reppen. A woman twenty-eight years of age, when in the fourth
month of pregnancy, in consequence of a violent effort had a prolapsus of the
uterus. Gestation nevertheless went on without any accident to full time.
When Dr. G. saw her thirty-six hours had elapsed since labour had set in, and
twenty-four since the waters had been discharged. The uterus hung between
the patients thighs, it was six inches long and eight thick. The vertex of the
child presented, and the neck of the uterus was dilated to the size of a two
franc piece. Not being able to obtain a greater dilatation. Dr. G., made an
incision three inches in length in one side of the neck of the uterus, and a
dead but well developed child was extracted. The delivery of the placenta
was attended with very profuse haemorrhage, which was arrested by injections
©f cold water. Afterwards the uterus was reduced and every thing went on
well. The woman recovered and notwithstanding the advice of Dr. G., refused
to wear a pessary. — Ibid,

508

Progress of the Medical Sciences,
MEDICAL STATISTICS.

44. Statistics of Patients Jlffected with Calculus, admitted into tjic Hospital of St.
Mary at Moscow. — Dr. De Roos, of St. Petersburgh, states that during the 28
years, from 1808 to 1836, 1411 patients affected with urinary calculus were
admitted into the Hospital of St. Mary at Moscow. During the 7 years, from
1830 to 1836 inclusive, 469 calculous patients were admitted, of whom 411 were
operated on, and 369 of them cured; 41 left the Hospital uncured, 23 died within
the first week after the operation, 19 died after the operation in consequence of
other diseases, and 17 died without being operated on.

The following table shows the ages of the patients, and results of the cases,
admitted during the 7 years from 1830 to 1836 inclusive:

Number of

Cured by

Discharged,

Pied with-

Died, within

Died with-

AGE.

Patients.

Lithotomy.

not Opera-
ted on.

in a week
from the
Operation.

a momli or
longer alter
the operation,
from other
diseases.

out being
operated
on.

2 years.

3 years.

4 years.

5 years.

6 years.

7 years.

0 .

8 years.

0 .

9 years.

10 years.

11 years.

12 years.

13 }mars.

14 years.

15 years.

16 years.

17 years.

18 years.

19 years.

20 years.

21 years.

22 years.

23 years.

24 years.

25 years.

27 years.

SO years.

31 years.

' 0

33 years.

34 years.

35 years.

36 years.

38 years.

39 years.

40 years.

45 years.

53 years.

55 years.

61 years.

Total,

469

369

Gaz. Med. de Paris, December 26?, 1838, from Medicinisches Correspondenz —
Blatt.

Medical Statistics.

509

45. Prussian Bills of Mortality. — Results gleaned from the Register of Births^
Marriages.) and Bills of Mortality in the Prussian dominions., during the year 1836.
Officially reported by the Government.* From the Statistical Journal and Record
of Useful knowledge, for November, 1837: London.

In the twenty-five government districts of the Prussian States, the amount
of births and deaths during the year 1836 was, births 550,622, deaths 375,588;
increase through the surplus of births 175,034. The total number of inhabitants
in the Prussian dominions, exclusive of the principality of Neufchatel, was, at
the end of 1836, 13,837,233.

Throughout the report, the number of 100,000 persons is taken as the basis
of the calculations. In the year 1835, the births exceeded the deaths, 1127 in
100,000; in 1836, the excess was 1296; in the two years the excess amounts to
2423, or nearly 2 and 3f per cent.

Since 1836, the ratio of mortality to the population has increased, notwith-
standing which, the natural increase of population is such, that, should there be
no variation, it will be doubled in about 58 years.

The following estimate, made on an average population of 100,000 souls,
shows the relative numbers of the births and deaths, together with the surplus
of the former.

the Government Districts of

Births.

Deaths.

Surplus.

Coslin

4136

2048

2088

Stettin

4146

2277

1869

Marienwerder

4681

2865

1816

Bromberg -

4574

2785

1789

Frankfort -

3877

2315

1562

Dantzig

4255

2702

1553

Stralsund -

3877

2340

1537

Posen

4117

2679

1338

Potsdam -

3963

2542

1421

Mersburg -

4018

2634

1384

Dusseldorf

4036

2655

1381

Minden

-4398

3025

1373

Treves

3855

2508

1347

Arnsberg -

*■

3953

2708

1245

Magdeburg

3784

2557

1227

Coblentz -

3949

2739

1210

Erfort

3894

2706

1188

Koningsberg

4071

2957

1114

Cologne -

4073

2962

nil

Oppeln

4810

3761

1049

B reslaw -

4818

3070

1048

Aix-la-Chapelle

3726

2697

1029

Gumbinnen

4141

3127

1014

Lignitz

3930

3149

781

Munster -

“ ■

3169

2471

698

[n the Prussian dominions generally

4076

2780

1296

From the above statement it appears that the births exceeded the deaths in all
the districts, which are ranged so as to show the greatest amounts first and the
smallest last. In Munster, the surplus of births is little more than a third of
the amount in Coslin. Munster had by far the smallest proportion of births,
namely, only 1 between 31 and 32 inhabitants. As the mortality is only 1 in
between 40 and 41 inhabitants, which is under the average for the whole country,
the small surplus of births is entirely owing to a deficiency of these and not, as,

* For a statistical view of the births and deaths in the Prussian States, in the 15
years from 1820 to 1834, see No. XLII of this Journal, (Feb. 1838,) page 447.

43*

510

Progress of the Medical Sciences.

might be supposed, to an increased mortality. This fact being regularly obser-
vable every year, shows that it must depend upon some circumstances peculiar
to the district.

Of all the government districts of Prussia, Coslin presents the smallest
amount of mortality, viz: not quite 2^ per cent., or 1 to nearly 49 inhabitants.
This chiefly explains the reason why the surplus of its births is so great, since
it exhibits by no means a very large proportion of births, which only amount
to 1 in rather more than 24 inhabitants.

From a comparison of the districts of Coslin and Munster, with reference to
the ages of persons who died in those places in 1836, it would appear, that the
proportion of deaths in 100,000 inhabitants was as follows:

Coslin. Munster.

Children under the age of 1 year, including those w^ho
w'ere still-born, - - - - - - 596

Children from the commencement of the 2d year to the
completion of the 14th year of their age, - - 338

Adults from the commencement of the 15th to the com-
pletion of their 70th year. . . _ . - 840

Above 70 years of age, 274

All ages added together, -

- 2048

501

512

1062

398

2471

From the above statement it would appear, that the proportional mortality of
infants under one year is rather greater in Coslin than in Munster; but in the
period embraced between the completion of the 1st and 14th years, a striking
disparity exists, the amount of mortality in Munster being almost a third more
than that of Coslin. In the active period of life, viz: from the age of 15 to 70,
the deaths in Coslin are only 840, and in Munster 1062, in a population of
100,000. But, in the former place, there were comparatively fewer individuals
of the ages between 15 and 70, than in Munster; because, owing to the rapid
progress of population, there were more children to an equal number of inhabi-
tants, and, consequently, the mortality in these two districts difl'ers far less in
the active period of life than in childhood. It is the same with respect to that
part of the population above 70 years of age. Among an equal number of inha-
bitants there must be more above the age of 70 in Munster than in Coslin; but
then there are also more deaths among persons of that age in Munster. Hence
it may be inferred, that circumstances are peculiarly unfavourable to youth in
Munster.

Next to Coslin, the districts of Stettin, MarienWerder, and Bromberg, pre-
sented, in 1836, the greatest surplus of births. In comparing the district of
Oppeln with Coslin, w^e find that the proportional mortality of children under 1
year is much greater in the former, amounting to nearly a fifth of the whole mor-
tality, w’hilst in Coslin it is only about one-sixth. But the most striking dif-
ference exists among children from the beginning of the 2d year to the end of
the 14th, there dieing in Oppeln nearly three times as many as in Coslin. The
great mortality in Oppeln is not altogether owing to the prevalence of ordinary
epidemics, the ravages of which are usually confined to particular years, but is
to be ascribed to the annual recurrence of diseases dependent upon permanent
circumstances. Even in the active or business period of life, between 15 and
70 years of age, the mortality of Oppeln is found to he considerably greater than
that of Coslin, in the proportion of 7 to 4. The mortality falls- heaviest upon
the younger part of the class, for, late in life, the deaths are so much diminished,
that, though the number who died above 70 in Oppeln is proportionably greater
than in Coslin, yet the relative proportion, on the same number of inhabitants,
is only 5 in Oppeln and 4 in Coslin.

The number of marriages contracted in 1836 throughout the Prussian States
was 125,391, being in the ratio of 928 new^ marriages on an average of 100,000
inhabitants, or about 1 marriage to about 107 persons. In particular districts,

Medical Statistics.

511

the ratio of marriag-es to the population varies considerably. Thus, in Oppeln,
which shows the greatest proportion, there were 1075 to 100,000 persons, whilst,
in Treves, which has the least proportion, the same number of inhabitants give
only 790.

The number of marriages contracted is considerably influenced by accidental
circumstances; the proportion has, however, been progressively increasing of
late years, as shown in the following statement:

In the Year
1820

New Marriages.
109,625

1821

106,000

1822

106,160

1823

102,247

1824

- .

107,472

1 825'

112,171

1826

111,999

1827

106,270

1828

. ,

104,788

1829

108,627

1830

110,534

1831

98,673

1832

127,217

1833

130,540

1834

. '

129,494

1835

. ^

123,953

1836

125,391

Although the population during the years enumerated has increased with a
pretty regular progression, the number of marriages between 1820 and 1830
fluctuated between 102,247 and 112,1 71. The alarm occasioned by the cholera
in the interior and eastern parts of Prussia in 1831, diminished the number of
marriages to 98,673. Since then, however, the number has increased so as to
range between 123,953 and 130,540. The cause of the first increase in 1832,
may probably be assigned to the celebration of those marriages which had been
agreed upon previously to the breaking out of the cholera, and deferred during
its prevalence. But this cause does not account for the continued increase of
marriages during the subsequent years, at a greater rate than the proportional
increase of population.

The number of children born in wedlock, in the course of 1836, was: —

Boys .... 263,960

Girls .... 248,500

Out of wedlock: —

Boys

Girls

Together

512,460

19,540

18,622

Together ... 38,162

Total .... 220,622

Accordingly, of 100,000 children, 6931 were illegitimate; and, therefore, less
t'nan but more than ~ of the children born were illegitimate; or, lo be more
accurate, of all the children born ,-jty were illegitimate.

These, also, have been the usual proportions for several years past in the
Prussian dominions.

The places furnishing the smallest proportion of illegitimate births are situated
in Westphalia and the Rhenish Province. In these districts, the proportion

512

Progress of the Medical Sciences.

varies from 224 to 94 in the 100,000. In the four districts of Marienwerder,
Bromberg', Posen, and Oppeln, which are, to a great extent, inhabited by de-
scendants of the Sclavonic race, the illegitimate births vary from 265 to 218 on
every 100,000. Coslinand Gumbinnen furnish respectively 275 and 278 illegiti-
mate births to the 100,000. In the above named districts, the moral habits of
the great mass of the people produce the most decided effect; for, as to other cir-
cumstances which might exert an important influence, such as descent, religion,
legislation, manufactures, density of population, and the concentration of inhabi-
tants in great towns, there is much variation in those districts, without affording
ground for drawing any precise inference on the subject. In the small district
of Erfort, which, owing to the irregular position of its territory, varies so much
in its manufacturing and moral relations, the average number of illegitimate
births is, incidentally, just the amount of the average for the whole of Prussia,
namely, 282 for every 100,000 inhabitants, or rather less than 1 in 13 of the
whole number of births. In the ten districts, also, where the average number
is exceeded, no particular circumstance can be referred to as explanatory of the
cause.

In the great towns of Prussia, the proportion of the illegitimate children born
during 1836, to the number of inhabitants, was as follows on every 100,000: —

Towns.

Illegitimate Children.

Breslavv . - - .

Konigsberg -

- - - 61

Berlin _ - _ _

Posen _ _ _ -

Danizic - - - .

Cologne, with Deutz -

Stettin -

Magdeburg - - -

Aix-la-Chapelle -

Elberfeld, with Barmen

Here, again, is displayed a remarkably small number of illegitimate children
born in the province of the Rhine; but it may be still more difficult to explain
why, under relations so different, Berlin and Posen have an equal number of
illegitimate births; and, on the contrary, why, under similar relations, the num-
bers should be so different in Konigsberg and Stettin.

It is ascertained, by experience, that in a great part of Europe the number of
males, in comparison with females, does not bear the same proportion among
illegitimate children as among those born in wedlock. In the fifteen years from
1820 to 1834, on an average, for 10,000 females, the males were — born in wed-
lock, 10,597 — the illegitimate. Only 10,310. the surplus of boys, therefore, in
the first case, amounted to nearly 6, and in the second case to only 3 per cent.
In the single year, 1836, the difference was less; for instance, in that year there
were, for 10,000 female children, 10,622 males born in wedlock, and 10,494
illegitimate. Whether the difference between the one surplus and the other be
merely an accidental fluctuation or a permanent change, we are not at present
able to determine. G. E.

5i3

AMERICAN INTELLIGENCE.

On the Value of the Catoptf'ic examination of the Eye as a means
of Diagnosis. By I. Hays. M. D. — Since the publication of the preced-
ing No. of this Journal we have met with several cases which strikingly
illustrate the value of the catoptric examination of the eye as a means of
diagnosis. One of these we will relate.

Mr. T. a farmer, setat. thirty, whilst employed last November, in
feeding a threshing machine, was struck in the left eye by a grain of
wheat projected from the machine, which made a small wound in the
cornea near its nasal margin. Severe inflammation followed, with loss of
vision, for which he was judiciously subjected by Dr. T. A. Worrall of
Lewistovvn, Penna., to a strict antiphlogistic treatment followed by an
alterative course of mercury, &c. Some time after the inflammation had
been subdued Mr. T. found that his vision with the left eye began to
return, and it continued to improve until he. was able to distinguish large
objects, to count the number of Angers held before his eye, &c., but he
could not read even large type. Being desirous of recovering his sight
entirely he came to the city to consult us.

When w'e flrst saw him, which was six months after the injury, the
eye was entirely free from inflammation, and the only abnormal appearance
we could detect by the ordinary method of examination was a small cicatrix
near the nasal margin of the cornea to which a minute portion of the
margin of the iris was adherent, and the pupil consequently was slightly
irregular. 'I'his was not, however, sufAcient to account for hi^ imperfect
vision; and w'e were inclined to attribute the defect to some injury of the
internal tissues of the eye, probably involving the retina, from the inflam-
mation which had followed the injury.

Rather as a matter of curiosity than with any expectation of detecting
the cause of the defective power of the eye we determined to examine this
organ caloptrically. A solution of belladonna was dropped in it, and when
the pupil wa^ partially dilated a liglited candle was held before it, when to
our surprise the only image we could perceive, though the pupil was per-
fectly clear, was the Arst upright one; indicating that the other reflecting
surfaces were absent. (See preceding No. of this Journal, p. 255.) In a short
time the pupil became fully dilated, and there was then visible a very
small opaque substance just behind the upper and outer edge of the iris.
This was a portion of opaque capsule. Me did not then hesitate to state
to the patient that the lens of his eye must have been dislocated by the blow
from the grain of wheat, and been subsequently absorbed; that he was in the
condition of a person wlio had been operated on for cataract, and required
only a proper lens on the outside of his eye to enable him to see. 1 accord-
ingly accompanied him to Mr. M’ Allister’s, in Chesnut street, and having
procured a suitable pair of spectacles, he found, to his great delight, and
scarcely less to mine, that with them he was able to read, with perfect
facility, small print.

5 1 4 American Intelligence.

Note on Extraction of Foreign Bodies from the Eye. By I. Hays,
M. I). — Since our remarks on this subject (p. 282 of tiiis No.) were
printed off, we have had occasion to remove from the eye of a patient
a fragment of stone about two lines long and one and a quarter thick,
of an irregular shape, somewhat resembling a double pyramid applied
base to base. It had penetrated the cornea near its nasal margin, and
fallen into the lower part of the anterior chamber. The accident had
occurred ten days previously. A small incision was made at the lower
part of the cornea with a cataract knife, and the stone grasped with forceps,
but from its shape it could not be retained. A second trial having been
equally unsuccessful, and not wishing to incur the risk of injuring the
delicate tissues of the eye by repeated attempts, I bent an Anel’s probe
into the shape of a hook, introduced it through the incision and readily
extracted with it the piece of stone. 'Bhis instrument may in some cases
be usefully substituted for the forceps, when the foreign body is of such a
shape as not to be easily held in the grasp of the latter, and we have
written this note to recommend it for that purpose.

Cases of Negro Poisoning. By Alexander Somervail, M. D. of
Essex County, Va. — In May 1800, I became a sufferer from diarrhoea;
such as I then thought different from any species of diarrhoea I had heard
of. It was accompanied with much griping, and large evacuations of a
dun colour, frothy, and of the consistence of molasses. I determined to
take some cathartic to carry it off, from a feeling of some irritation acting
within. I fortunately took an ounce of cream of tartar, which removed
the complaint — it returned and was removed two or three times, until I
noticed that it always returned after dining at a certain house, where I was
obliged to be. I soon was satisfied it was accomplished by the man-ser-
vant at the table; and though taking all care, I could not escape until he was
taken sick and confined at his wife’s several miles off. I then could eat
and drink there with safety. When he returned I was taken again. I
then endeavoured to avoid eating there, and gave offence thereby, so that I
v/as obliged to tell why I kept away. As long as I forbore to eat there I
was well. In September, I was obliged to be there several days; and
before leaving there, I thought I saw him take the opportunity of handing
me a cup of tea, to put something in. I examined it attentively, and per-
ceived nothing amiss. I therefore drank it, and soon after took leave; on
my way home in about half an hour, I was in great pain; vomited with
relief, but diarrhoea followed. Next day, I had to ride twenty miles from
home and return, and as I had often restrained the diarrhoea by a few
drops of laudanum to allow me to go on, I ditl so now. When about two
miles from home, in returning, and nearly dark, I was obliged to get
down, and there to stay for two long hours, and with difficulty reached
liome. I took my dose at once, was relieved before it operated, and ano-
ther dose next day removed all uneasiness. The servant was sent away
at the end of the year, and I remained free.

In 1814, I had offetided our cook; she brought the diarrhoea upon me
again; at first, slight, and being aware of her, I got along tolerably till the
summer of 1816. I thought she had such things placed by me at table as
she knew I would use, or in the bread directed to be given to me, so that
I only at the table was affected. Now she became more determined, and
I could not prevent it. I was obliged to take cream of tartar almost daily,

American Intelligence.

515

and my fjimily entreated I would not take any more, believing I would die
if I did; but that was my only help. After taking my dose in her pre-
sence, and knowing why I took it, and no person near, I told her if I was
obliged to take any more, I should come prepared to kill her, as there was
no other chance for me to live; but if she would let me alone I would for-
give all; so she let me pass. Soon after, being a hired servant, she became
the property of another master who sold her. There was an old negro
man whom I saw frequently cure such patients, and recommended him,
who heard of my situation, and offered his services to me, but as I w’as
getting well and knowing iiow powerfully his remedy operated, I refused;
he said he would give me a small portion which I took with advantage:
this was a decoction of the root of the Podophyllum Peltatum, and which
I have often used in similar cases with great advantage. When this diar-
rhoea continues, the pain ceases, and it comes on suddenly without warn-
ing, so that it is difficult to get to a suitable place, sometimes impossible.
I believe diarrhoea is always brought on by acrid matter generated in the
alimentary canal, or taken into it; the method of cure must be to remove
the cause and prevent its reproduction. When from acrids taken in this
must be prevented, and when done by our slaves it is very difficult. I
believe they never miss an opportunity until death is effected, unless it is
put out of their power. There is much of it, and by various articles, pro-
ducing various diseases.

'J'his is the diarrhoea mentioned by Dr. Chapman as occurring at New
Orleans, and Richmond in Virginia. After the diarrhoea is checked or
removed, other remedies are necessary to restore health; my dependence
for that has been the tinct. ferr. mur. I will add to this a case of negro-
poisoning of a different character.

In August, 1802, a young married lady, and near neighbor, had inter-
mittent fever, and applied to me. I gave the usual remedy, and had no
doubt of success; this did not answer, and without telling me, she sent off
a dozen miles for a more experienced physician. I heard of this, and one
evening she sent for me in all haste, saying, unless relieved she should die.
I found her vomiting an indigo coloured fluid, with great anxiety, and diffi-
cult respiration, pulse small, feeble and slow. I gave laudanum which
quieted all things for the night. Her physician was sent for as well as
another to whom we looked up. When we met I suggested poison as the
cause, for which I was ridiculed, but the prescription agreed upon at once,
was such as my opinion approved. After drinking a pint of water from
the spring she took four grains of sulphate of copper in half an ounce of
water, and water after it. This was soon brought up, and the water and
sulphate repeated as soon as we could; when this was vomited freely, all
uneasy feelings were removed; it ought to have been mentioned, that when
we met she was vomiting, &c., as when I saw her the evening before.
Various remedies were prescribed, and I was directed to repeat the emetic>
whenever the sickness, anxiety, &c., returned. This I had to do every
day, and sometimes twice for several days, and always with relief, until I
told what I believed was the cause: after that we had some days of greater
suffering before they would agree to my proposition. This was for me to
bring from home every thing she ate and drank. After another emetic,
this was done; she recovered daily, and at last said she was well enough to
live as usual. While all this was doing, many attempts were made by
their negroes to bring her such things to eat as they knew she liked; but

516

American Intelligence.

all was faithfully resisted. In a few days after we left her, I was sent for
again, had to repeat the emetic, and send her on a visit to a friend where
her negroes could not go; she did not complain any more.

I know very well this idea of poisoning by our slaves is ridiculed by
most medical men: but it is sometimes said “ seeing is believing, but feel-
ing is the truth. I have seen and felt what I have here written; the facts
are indisputable whatever the cause may be.

Loretto, Essex County, Va., March 7, 1839.

Case of Exostosis of Upper Jaw, successfully treated hy B. A. Rodri-
gues, M. D. of (Charleston, (communicated by Professor Geddings.)

On the 14th August, 1837, Charity, a servant woman of Mrs. Miller,
called on me to ascertain whether I could afford her any relief in her
wretched condition. She had been labouring under incessant and agoniz-
ing pains in the antrum higlimorianum of the right side, which she regarded
as the consequence of the impaired condition of the teeth. On this sup-
position, she had several of them extracted, without any appreciable abate-
ment of her sufferings. Yet deluded with the belief that some one of the
remaining teeth was the secret agent of all she suffered, she persisted
in having more extracted. Still the evil continued, the suffering was
unabated, the cause undetected, and to add to the depression of her hopes,
and the aggravation of her ills, a purulent discharge oozed from the empty
sockets of the affected side. She again had recourse to medical advice,
hoping that this new phasis of her malady, might lead to some indication
that would relieve her; at least, that it might reveal its hidden sources, its
condition and its prospects of being remediable. And here for the first
lime, was it suggested that the antrum was in an unsound state.

It was at this moment, under these circumstances, that she applied to
me to perform an operation, which her medical adviser declared to be indis-
pensable. At first, I imagined it to be an abscess of the cavity from the
pus discharged, from the strange sensations experienced, and from the
greater frequency of this disease over others peculiar to this part. I
inserted a trocar into the socket of the second molar and instead of- the
gush of matter I had expected, the passage of the instrument was inter-
cepted by a hard dense impregnable substance. The existence of an exos-
tosis now forced itself on me. 4'o make assurance doubly sure, I_had
access to several of my medical friends, among whom was Dr. Geddings.
On examination of the part, the consideration of the symptoms, the obsti-
nate nature of the disease, they concurred with me in opinion, that an
exostosis was present, and that the sole indication of relief was its extirpa-
tion. Accordingly, on llie 18th of August, the above gentleman with seve-
ral others of the profession was present, when I proceeded to perform the
operation. With a common scalpel, I dissected away the gum from the
canine teeth to the last molar raised the flap which it made from the alve-
olar process, and with a trephine opened into the cavity. Success was
easier than had been anticipated in conseqnqnce of the carious condition
of the process which was so general on the affected side as to reach from
the second incisor anteriorly to the pterygoid process posteriorly. In the
loss of substance the external parietes of the cavity shared, so that the
bony tumour which filled up and occupied it could be readily reached, 'rhe
trephine was applied, the cavity enlarged, and the exostosis removed. It
measured in circumference three inches, was light, and cancellated on its

517

American Intelligence.

surface, but dense and resisting- in its more internal layers. There was
little or no hemorrhage to delay the operation, or any application to arrest
it. After removing every spiculum of diseased bone, and cleansing out the
cavity, the flap was replaced and to nature was entrusted the cure. Granu-
lations sprouted up in full luxuriance, and in the short period of four weeks,
the woman was in enjoyment of excellent health. It may be well to remark
that when I saw her for the first tim ^ the only untoward symptom the disease
presented that might have determined the diagnosis of exostosis, was the
occlusion of the nasal cavity. Respiration through this natural channel
was impossible, but such an obstacle I can readily conceive may occur
from a high and acute inflammation in the lining membrane of the part.
An incipient abscess is almost invariably announced by such an obstruc-
tion and a preponderance of the affection over the other naturally suggested
its existence. Bordenave and Abernethy have both noticed the presence
of exostosis in these cavities, but to my recollection there has been no his-
tory of them recorded, where the tumour was so large, where such exten-
sive injury was inflicted on the adjacent parts and where nature after the
causative malady had been removed, exerted her recuperative powers, so
benignly and so quickly. Its early history, its duration, its probable
causes, whether local or constiliuional, are involved in mystery, the
patient calling on me but a short time before the operation, and seemed
to know nothing more of it than her sufferings.

Notice of the Cape May Albinos. By Dr. Samuel L. Marcy. — The
two female Cape May Albinos, a short account of which may be seen in the
American Medical Intelligencer, vol. i, No. 12, Art. 3, continue in a
healthy condition. The mother seems destined to propagate a family of
them, having had three children, possessing all the peculiarities of the
African race, and three Albinos. Her two first children were fair male
representatives of Africa, then followed two female Albinos, then by way
of punctuation a black female, (now dead;) and on the first of June last,
commenced another line, with another Albino male. Her coloured chil-
dren being all dead, her family consists of three children, possessing a
more delicate skin than any white children I ever saw. The father and
mother, Peter and Kezia Humphreys, both fair emblems of the African
race, were born and apprenticed in the county of Cape May, and always
maintained a character for industry, integrity and virtue, far above the
majority of the common negroes of the neighbourhood. I shall not at-
tempt assigning any thing like a reasonable cause for this freak of nature
in this black and white family. The mother accounts for the appear-
ance of the first Albino, by attributing it to a severe fright she received,
by the falling down of an old white mare while she was driving her, at-
tached to a wagon. If the fright had any effect upon the child in utero,
why was not the child marked in form as well as colour? The mother
was accustomed to drive the mare daily: if the fright had had any effect,
it should have produced a half horse, half mule, or half alligator. At first
view I was unwilling to admit, that the Great Creator ever left his work
in so loose a manner, that the imagination of the mother should alter or de-
termine the form or colour, but the subsequent children go further to
strengthen the doctrine, that the mind of the mother may affect the fostus in
utero, than any fact that ever came under my notice. The mother evidently
suffered as much mortification and distress at the appearance of her white
No. XLVllI. — August, 1839, 44

518 American Intelligence.

offspring', as any respectable white lady would at becoming the mother of a
perfect Negro child; the mother appeared ashamed of, and very reluctantly
exposed her cliild to the gaze of tlie public; made use of every endeavour to
render the child dark, by exposing it to the rays of the sun, &c., &c.; her
mind dwelt incessantly upon the child, until the delivery of her second Albi-
no; and her first and immediate question on delivery was, “ what colour is it?”
If the thing is to be admitted as possible, here was a continued cause opera-
ting to produce the effect; after the birth of the second while child, she be-
came reconciled, and the suspicions of her husband, which had been exces-
sive, now subsided, and the affairs of life went on as smoothly as if the chil-
dren had been of the proper colour, and, in due lime, she gave birth to a
full-blooded African, and all was w^ell; and, in the proper course of lime, she
became pregnant a sixth time: about this lime her house was much fre-
quented by visitors from Philadelphia and elsewhere, to view' the “great
curiosity;” and by dint of much persuasion she consen'ed to visit Phila-
delphia with her children, and exhibited them at the Masonic Hall and
other places for several weeks, in September, October and November last;
the jeerings and ungentlemanly remarks made by, I am happy to say, a
few ignorant men, caused her much mental suffering, and revived all her
former recollections and associations; early in the winter she returned to
lier owm home desponding, and, on the first of June, gave birth to her third
and last Albino. The question now arises, w^as the above cause sufficient
to produ<*e these effects? or did the same cause that produced the first,
wliatever it might have been, continue to operate until it produced the third?
and w'hat really was the remote and proximate cause? I leave to physiolo-
gists, more able to determine than myself.

To those who have not had an opportunity of seeing these Albinos, the
following description may not be uninteresting; they have all the fea-
tures of a regular built negro child, flat foot and broad, leg inserted in the
centre of the same, with a natural curve of the tibia, thick lips, broad nose,
hair woolly, skin unusually delicate and fair, eyes light blue, cornea sur-
rounded by a delicate ring of pink or peach-blossom, the pupil encircled
with the samecoloured ring, giving to the eye a peculiar appearance; the sight
suffers by a strong light, which causes the child to apply its hand above the
eye for a shade; hair long and curly, resembling combed worsted in colour,
or awhile spaniel; eyebrows and eyelashes the same; intelligent, active and
playful; a perfect lusus naturae.

Cold Spring. N. J.. Aug. \^tli 1837.

[The preceding communication was mislaid, and has been only just re-
covered. The delay in its publication is due to this accident. — Ed.]

Abstraction of the Uterus after Delivery. — The following shocking instance of
malpractice is recorded in the New York Journal of Medicine and Surgery, by
Jno. H. Griscom, M.D. — “On the 7th of April, 1839, at the request of Ira B.
"Wheeler, Esq., coroner, I examined the body of Mrs. Cozzins, the wife of a
respectable mechanic. No. 328 Madison-street, at the time absent from the city.
I was assisted in the examination by Dr. S. C. Ellis, in the presence of Drs.
Nichols, Lobstein, and Walters. Before the examination, we obtained the
follov/ing history : Mrs. C. was delivered of a healthy, living child, about one
A. M., without any other assistance than her sister and a female friend, both
married, and the former a mother. The cord was tied and cut secundem artem;
but the placenta was retained beyond the usual time. Three hours having

American Intelligence.

519>

elapsed without its disengag-ement, the sister went for a physician and obtained
the services of Septimus Hunter, who represented himself to be a physician,
but was at the time a clerk in a drug store. Upon his arrival, he immediately
addressed himself to tiie task of removing the placenta, the successive stages of
which operation will be mentioned presently.

“ We were shown prior to the dissection, a mass of fleshy substance in a
washbowl, which I at once recognised as a uterus; also, in another vessel, the
placenta wms shown us, which was entire, but without a vestige of the umbili-
cal cord attached to it. The latter was subsequently discovered in a pail of
dirty water.

“ On stripping the body, the abdomen was found very sunken. The usual
incisions were made, and the following uncommon appearances were presented:
1st. A total absence of the uterus. 2d. The broad ligaments much torn and
ragged, and partly deficient. One fallopian tube was absent, but both ovaria
remained in situ. 3d. The upper extremity of the vagina was open and free, so
that the hand introduced from without would pass directly into the cavity of the
abdomen, and the intestines could be touched. The intestines were high up as
left by the contracting uterus. 4th. A considerable quantity of extravasated
blood was seen on each side near the ovaria, forming s*pots of ecchymosis be-
neath the membranes. No effused blood was seen, however, within the abdo-
men, except this. 5th. A laceration of the vagina, about an inch and-a-half in
length, a short distance from its superior extremity.

“ By reverting to the uterus, we found the deficient parts attached to it, viz:
one fallopian tube, entire; a portion of the broad ligaments, and about an inch
of the upper end of the vagina, which had been divided by an even circle,
though manifestly without the aid of any cutting instrument. The external
surface of the uterus was about half denuded of its peritoneal coat, leaving the
muscular fibres entirely bare. Its external surface was smooth, and the part
where the placenta had been attached very apparent, presenting a slight brown
colour. The whole organ was about the size of a child’s head at birth. Large
quantities of coagula were about the body; the bedding was thoroughly soaked
with blood, and a large puddle of it, of a bright red colour, covered the floor
beneath the bed.

“ The examination of an intelligent female witness before the coroner’s jury,
developed the following facts: — Immediately after the quasi doctor arrived, he
took hold of the cord, and making strong traction upon it, he completely inverted
the uterus, the placenta still adhering, pulling still harder, he severed the cord
from its attachment and gave it to the witness. He then took hold of the pla-
centa, removed it, and laid it aside, saying there was more to come away still.
He then grasped the uterus of the unfortunate patient, and by dint of ‘ excessive’
pulling, after about three quarters of an hour, (during which period he relaxed
his efforts occasionally to rest and remove his coat, the miserable patient con-
stantly uttering the most piercing and heart-rending cries, such as ‘ you are
tearing my heart out, &c.,’) he succeeded in dragging the uterus from its attach-
ments, and separated it from the body, holding it in his hands, and exhibiting
it as a proof of his prowess and skill, saying that ‘ he never had met with such
an extraordinary case before.’ When asked what it wms, he replied ‘either a
polypus or a false conception.’ During this brutal operation, the groans of the
suffering woman were at first strong and loud; these together with the force
which the man was seen to use, excited the alarms of the attendants, who
urged him to desist and allow other medical advice to be called; but with in-
credible hardihood he persevered, insisting that all was right, that she must
endeavour to be patient, and that he would be responsible fur her life. Towards
the close of the performance, her cries became more and more faint, and at
length entirely ceased. He thought she was endeavouring to support the pain
with patience, and encouraged her in so doing by words. When he turned to
look after her, and to feel her pulse, he found that she was dead.

“ It is due to the profession to say, that the performer of this horrible tragedy

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American Intelligence.

is not, de jure, a member of the profession, though he asserts that he has a
recommendation from three surgeons of the British Navy, of his medical profi-
ciency, and that he has had a large amount (three hundred cases) of obstetric
practice. He appears to be about thirt}-two or thirty-three years of age, and.
has been in this country two years.”

Another case of a similar character which occurred in the town of Pulaski,
New York, is quoted by Dr. Griscom. The details were furnished by Mr. T.
S. Markoe, an intelligent medical student, who was cognizant of all the facts at
the time of their occurrence, and saw the preparation.

“The woman had had a perfectly natural and easy labour. The child w^as
born and removed from the mother, but the placenta was retained. After wait-
ing a certain time, the practitioner in attendance judged it necessary to pass in
his hand in order to extract it. He did so, and as he thought, found the pla-
centa attached very firmly near the mouth of the uterus. He then undertook to
peal it off from its attachment, but found the greatest difficulty in doing so, it
was so closely adherent that repeated and long continued efforts were made
without success. Supposing, however, that the life of his patient and his own
professional reputation depended upon his succeeding, he redoubled his efforts
until, as he himself said, he was exerting a degree of force which made him
fearful for the consequences. During all this time the woman was screaming
loudly, and exclaiming that he was killing her. Still thinking that he had the
placenta, he persevered, until at h.st it yielded entirely, and he commenced to
extract. The extraction was strongly resisted by something, and much exer-
tion was still necessary to bring the mass down to the external parts. Labour-
ing under the same fatal delusion, he succeeded by dint of main force in bring-
ing it quite out from the body of the mother. ‘ Judge of my surprise,’ says he,
in the paper which he wrote in his defence, ‘ when 1 found that 1 had the whole
uterus in my hand.’ However, the mischief was done, and he thought all he
could do, was to separate the few remaining attachments, which he did, by tear-
ing them off, and put the whole out of sight as quick as possible. The girl to
whom was allotted the office of disposing of it, seeing in the whole procedure
something suspicious, fortunately preserved the specimen. The poor woman
immediately after the performance of this barbarous operation, began to sink,
and was soon in a dying condition. No hemorrhage ensued, but the shock to
the nervous system was such that she expired in about two hours.

“ On examining the uterus, it was found about twice as large as a child’s
head at birth, containing within its cavity, the placenta loose and unattached.
One of the ovaries had been brought away with the lacerated broad ligament;
the broad ligament of the opposite side and the fallopian tube, were torn through
quite near the uterus; the posterior surface of the uterus was rough and covered
with cellular shreds and without a peritoneal coat; the peritoneum still covered
the anterior and superior parts. The old man says that his mistake occurred in
this way: the edges of the os tincse being relaxed and protruding into the va-
gina, he mistook this protrusion for the edge of the placenta; passing his fingers
into the cw/ de sac which the vagina makes with the neck of the uterus, he per-
forated the coats of the vagina supposing he was separating the placenta. His
fingers were thus behind the ut«-iis which he proceeded to tear from its connec-
tions. From inspection of the uterus, it is plain that he separated it from the
peritoneum, over the whole posterior surface, and perforated this membrane at
its upper part. Supposing then that he had detached the placenta, he extracted
the uterus by main force, as above mentioned. The vagina was torn off very
short.”

The following further details are given by Dr. H. T. Noyes: — “‘On the
morning of April 29th, 1838, I was called in consultation wdth Dr. * *

^ * to see Mrs. W. who was in labour, and was said to be dying;

I arrived about one o’clock, A. M., and found myself in the midst of one of the
most unparalleled scenes of distress and agony that could well be imagined; the
doctor delivering what he called an ‘adhered placenta’ — the father and husband

American Intelligence,

521

of the patient, and the female attendants, uttering loud lamentations, and the
patient herself, at the top of her voice, telling the doctor he was killing her,
and begging him to let her alone: I placed my finger upon the pulse and found
that she was rapidly sinking, at the same time inquiring of the doctor what was
the nature of the case; he told me that it was an adherent placenta, such as he
had never before met with in his practice, or read, or heard of before, and that
he was nearly through with his delivery, and should finish in a minute or two,
which he did, in about the time specified, remarking to me ‘that it comes like
tearing raw sheep-skin,’ that the placenta adhered to the neck and mouth of the
uterus, and ihat there were some shreds of it left, but that he thought they
would be discharged with the lochiar.’ I told him that the patient was dying,
but at his request made a hurried examination per vaginam^ found shreds of
cellular tissue and membrane reaching nearly or quite to her knees, but found
no uterus; on telling him this he remarked that it was there, and had contracted
well, and placing his hand above the pubis, he said he could feel it contracting.
By this time, the woman, from the relaxation of the muscular power and the
near approach of death, began to slide from her seat, (made by tying three
chairs together) and was prevented from descending to the floor by my seizing
her under the arms and requesting assistance to lay her on the bed: after which
she lived about ten or fifteen minutes. From the time of my arrival to her
death was about twenty or twenty-five minutes; the attendants informed me
that the doctor had been at work an hour and a half in removing the supposed
placenta before I arrived. 1 would, finally, remark that the patient was a large
and rather fat woman, that this was her fourth child, which was large and
healthy, that the labour had continued about fifteen hours, the doctor himself
admitting, that it was tolerably easy, and that the woman was quite comfortable
after the delivery, until he commenced operating.’ The same letter contains
the information that this individual is held to bail for the sum of ^500 and that
his trial will probably take place the ensuing autumn.”

A third case is recorded by Bartholin, and a fourth by Mr. Cooke. {^Med,
CJiirurg. Rev. April 1836. p. 482.)

Successful Treatment (f Erysipelas hy Raw Cotton. — Dr. F. M. RoBertson,
of Augusta, Georgia, in a communication in the Southern Med. and Surg.
Journ. (July, 1839,) states, “ that he has employed raw cotton, in the
treatment of erysipelas, as recommended by M. R'eynaud, with very satis-
factory results. Two cases in which it was employed, are related. One
of these was a little girl who had a week previous, accidentally received
a small wound, which penetrated through the scalp to the cranium.
The wound had suppurated, and, on close examination. Dr. R. found that it
had taken on ei*ysipelatous inflammation, which had extended to the right
ear, and, on the forehead, as far as the nose and appeared to be progressing over
the entire scalp and face. It wms in the afternoon when Dr. R. saw her:
during the morning, the febrile excitement was high, and she had been, occa-
sionally, delirious. Dr. R. immediately had the hair cut as close/ as it could be,
with a pair of scissors, and a cold bread and milk poultice applied to the wound,
and the entire scalp and forehead covered with the bats of cotton, as in the
former case; at the same time, a dose of calomel, to be followed by epsom salts,
w^as administered. The relief from the cotton was immiediate; all the bad symp-
toms wmre relieved, and, after the operation of the medicine, the general excite-
ment was moderated and the delirium did not return again. In this case the
inflammation progressed as far as the cheeks, and to the left ear. The cotton
could not be applied over the eyes and nose, as the patient was too young to
understand the importance of submitting to such a cumbersome application; it,
however, arrested its further progress from the cheeks and scalp. All the local
symptoms were relieved as soon as the cotton was applied; no blisters formed
on the forehead or cheeks, and the desquamation of the cuticle was very slight;
much less than I have ever seen it in the mildest case of this disease, when
treated without cotton. During the progress of this case, which lasted for seven

44*

522

American Intelligence.

days, the only internal medicine administered, except the first cathartic, was an
occasional saline aperient and cold lemonade or soda water, made by dissolving
the common soda powders of the shops.

Case illustrative of the Etiology (f Spoutaueous .imputation of the Limbs of
the Foetus in Utcro. By A. H. Buchanan, M. D. of Columbia, Tennessee. — In
the month of February last, I was called in haste to the country, about 3 miles,
to see a negro woman w'ho was said to be suffering from severe pain in the back,
and uterine hemorrhage. She w'as the mother of ten children, aged about 40
years, and had miscarried three or four times. On my arrival, I found she had
aborted, and that the uterine hemorrhage had ceased. Upon an examination of
the foetus, which was between three and four months old, and perfectly formed,
except a considerable flattening of the head laterally, 1 found the umbilical cord
twisted about the thigh and neck in the follow ing manner: the cord passes from
the umbilicus under the right thigh, just above the knee joint, and continuing
completely around it, passes under itself, and ascends in front of the chest to
the right side of the neck, around which it twines twice, or rather twice jand an
half, so that two coils are seen in front of the neck, and three behind; it then
passes in front of the left shoulder to the placenta. From the compressed
appearance of the cord opposite the left shoulder, 1 think it passed under the left
armpit to the placenta. Thus circumstanced, it is evident that any efforts made
by the child to extend the thigh tightened the cord about the neck, and also
about the thigh, as well as dragged upon its umbilical extremity, and obstructed
the circulation. The same effects also are produced by extending back the head;
but in this last action, the placental extremity of the cord is immediately pulled
upon. It is very fair to conclude that the foetus thus situated came to its death,
either from the compression of its throat by the cord, or from its obstructed cir-
culation, or from both; and that the abortion was a consequence of its death At
many points where the cord twists upon itself, it is very much compressed, or
rather atrophied. But the object of conjmunicaiing this case, is to call attention
to the effects produced upon the the thigli by the twisting of the cord around it.
It may be seen by any present, that at the point of compression, only the integu-
ments intervene between the cord and bone, all the other parts having disap-
peared; but the linib below tlie ligature, appears as fully developed as its fellow,
and the integunrents immediately under the ligature appear sound. Now it is
highly probable, had the child lived to its full time, the leg would have been
amputated by the process of absorption carried on in consequence of the pres-
sure of the cord around the limb, and that the opposite surfaces would have
healed as is usual in such cases, during the process of amputation; the limb
below the ligature retaining its vitality by its connection with the integuments,
they being the last parts to give way during the amputation; that the leg below'
the knee joint would have been more or less atrophied before its complete sepa-
ration, is almost certain. — Minutes of the Med. Soc. Tennessee, May, 1839.

Fresh Vaccine Virus. — Dr. Charles A. Lee of New York, informs us that
he has lately obtained virus from a cow affected with kine peck. “-It is very
common,” he states, “ for the cows that go on board our New York, Liverpool,
and Havre packets, to have this disease; and the cow from w hich I got it came
from one of these packets. The agent informed me that there is hardly a time
in the year, but that some of the cows are affected with it.”

Dr. BartkWs case <f Double Consciousness. — Dr. Bartlett writes to us that
R. M., whose case is reported in our preceding number, p. 42, died about noon.
May 21. “ The evening before, she took, in the course of an hour, twenty-eight

grains extract of stramonium. She had before taken twenty with impunity. I
had some months ago, prescribed two grains every six hours, for the spasniodic
cough. She had gradua ly increased the quantity till she arrived at the dose just
stated. She was comatose throughout the night, ai d up to the lime of her death.

“ Dissection threw no light on the peculiarities of the case. There was very

American Intelligence,

523

great vascularity of the membranes of the brain; and thinning and redness of
the gastric mucous membrane. The scalp was a full quarter of an inch in thick-
ness, and rigid as sole leather.”

Albany Medical College and the Thomsonians. — “It appears from the Albany
Journal of the 20th of June, with which we have been favoured by a Corres-
pondent, that the Thomsonian Medical Society of the State of New York held,
their fourth annual meeting at the Senate Chamber, of the State House, in the
city of Albany, June 11th, 1839. This would be news of but little interest to
our readers; not so some of the events that transpired.

“It appears, from the published statement of the proceedings, that an invita-
tion was given for the Society to visit the Albany Medical College, and that a
committee was appointed ‘to wait upon Dr. March, President of the Faculty,
and ascertain when it would be his pleasure to receive the Society at that Insti-
tution;’ that ‘the committee appointed to wait upon Professor March, reported,
that the professor would entertain the Society at the Anatomical Museum of the
College’ at a certain hour'. It was then resolved, ‘that it is in the opinion of
this Society necessary to raise the standard of medical education among Thom-
sonian physicians,’ (a necessity, by the way, which has always been contested,)
‘ we recommend the students of the Thomsonian school to acquire a more
thorough knowledge of anatomy, physiolog)^ surgery and chemistry.’

“The committee visited the Professor at the time appointed, and were ‘ enter-
tained’ by him; after which the following resolutions were in all gratitude
passed unanimously; and the Albany Cclleije now holds the exalted position of
being the first, we believe, of the Medical Institutions in the United States, pub-
licly patronued by the Thomsonians!

Miesolved, That the thanks of this Society be tendered to Professor March,
for his generous invitation to visit the Albany Medical College this day, and
for the courtesy with which the Society were treated while there; also, for the
liberal proposition ‘to receive with kindness into the classes of anatomy, phy-
siology, surgery and chemistry, Thomsonian students upon the same terms as
other students of the College.’

“‘Aeso/my, That this Society commend the Albany Medical College to the
favourable notice of all the Students of the Thomsonian School, that wish to
acquire a more thorough knowledge of anatomy, physiology and surgery.’ ”

We have copied the })receding notice from the American Medical Library and
Intelligencer (July 1, 1839,) and need only remark in the words of the editor of
that journal, that “ comment on these unique proceedings is unnecessary.”

Remarks on Enlargement of the 7’onsils, attended by certain Deformities of the
Chest. By J, Mason Warren, M. D. of Boston. — The object of this interesting
paper, is to point out by the exhibition of a number of cases, the certainty and ease
with which the operation for excision of the tonsils may be performed with the
present improved instrument, and the great relief always experienced by theremc-
val ot these organs when in an enlarged state. Whilst nothing original is in-
tended by the author in his remarks on certain deformities of the chest which
complicate tliis disease, they may serve to draw attention to the relation which
exists between the enlargement of the tonsils and this affection.

“In 1827, M. Dupuytren published a paper,” Dr. Warren remarks, “on the
lateral depression of the parietes of the chest, consisting of a depression more or
less great of the ribs on each side, and a proportionate protrusion of the sternum
in trout, accompanied by some antero-posterior curva,ture of the vertebral column.
A portion of these cases occurred in children of a scrofulous habit, and were in-
variably accompanied l>y an enlargement of the tonsils.

“ The symptoms described by M. Dupuytren as attending this disease, were
habitual shortness of breath, ami difficulty of enunciation. W'ith infants there
was great difficulty in taking the breast, the child being threatened with suffo-
cation whenever the nipple was detained for any length of time in the mouth.
During sleep, the mouth was kept habitually open, and the respiration accom-

524

American Intdigenee.

panied by great noise, and frequently interrupted by frightful dreams and cries.
“These symptoms,” says M. Dupuylren, “may be increased so as to prevent
the development of the vital functions, and cause death in the earliest period of
life When these difficulties do not induce death immediately, they may de-
stroy life at a later period, either in preventing the child from taking the breast,
or in so altering ti>e nutrition as to prevent the development of the strength of the
different organs; in this case death does not at once take place, but the child
lives in a miserable state of feebleness and emaciation, which deprives him of
the greater part of his faculties.”

“In 1827, shortly after the publication of this paper, Mr. Coulson, of London,
published some cases in confirmation of those given by Dupuytren, adding, also,
three cases of his owm, of a deformity of the chest, ditferent from that before de-
scribed. “The external appearances of the chest,” says Mr. Coulson, “ in this
second kind of deformity, are directly the reverse of those which we have just
been considering. The sternum is hollow or concave anteriorly, the sides of
the chest are very prominent, and the spinal column but slightly, if in any
degree, altered from its natural shape; this is not so frequently congenital as
the former kind, but frequently occurs in persons of a weak habit, who are nar-
row-chested, and stoop a great deal. The constitutional symptoms are very
much the same as those attendant on the other kind of deformity.” On the
three cases appended to the paper of Mr. Coulson, and three of the four cases of
M. Dupuytren, enlargement of the tonsils existed; but in none of them does it
appear that removal of these organs was practised, although it is stated that
in one or two of them the tonsils were so large as nearly to fill up the posterior
part of the fauces, so that we are not enabled to judge of what would have been
the change effected on the symptoms referred to the chest, had this operation
been performed.

“ V\ ithin the last two years twenty cases have occurred in our practice, in which
it was thought necessary that an operation for the removal of the tonsils should
be practised: in nineteen of these cases the operation was successfully per-
formed; in one case the tonsils projected so little into the throat, as to make it
impossible to seize them with the instrument. The operation was temporarily
deferred. Of these twenty cases, fifteen were children, or less than tw^elve
years of age.

“ Of the fifteen children, eleven had more or less deformity of the chest, con-
sisting, in the greater number, of a projection of the cartilages of the ribs for-
wards, with a considerable excavation of the sternum. In these patients very
little curvature could be detected in the spinal column.

“In the five adults, no alteration of the parietes of the chest was perceptible.

“ The symptoms occurring in these patients were as follows:

“ In every one of them was more or less difficulty in respiration, in many cases
the noise being so great during sleep as to make it impossible for any person to
sleep in the same room; the sleep was often disturbed by frightful dreams.

“In many of the patients there was great difficulty of swallowing, liquid food
being often regurgitated into the nostrils; in one case, no solid food could be
taken without the previous use of a powerful astringent. About half the cases
were attended with severe constitutional symptoms.

“ In one case entire deafness was present. Some of the patients were liable to
periodical attacks of fever; in one case, a child, five years of age, returning, lat-
terly, as often as once a fortnight, and lasting three or four days. Eight of the
fifteen children showed more or less marks of a scrofulous habit. Eighteen of
the patients had both tonsils removed; the other patient being so much relieved
by the removal of one tonsil, tiiat it was unnecessary to have the operation re-
peated on the other side.

“In about half the patients this operation was performed on both sides the same
day; in the others a week was allowed to elapse before the other tonsil was
removed.

“In eighteen out of the nineteen cases, almost immediate relief was afforded to
all the symptoms; in the other case, no great relief was apparent, and this

525

American Intelligence.

seemed to be attributable to the particular shape of these organs, the base being
quite broad, and extending some distance down the throat, about half of each
tonsil was removed. A.t the end of a sliDrt period, an appearance was presented
as if they had been again regenerated; this arose from the upper and lower por-
tions rising or curling up, as it were, after the apex had been removed. At the
end of two years, this patient submitted to a second operation, followed by much
relief, and is now in a fair way of recovery.

“The operation, as performed by the present improved instrument, is instan-
taneous— not attended with much pain — in no case was there any considerable
hemorrhage — usually nothing more than a few mouthfuls of blood are dis-
charged. The patients are able to return home and resume their ordinary occu-
pations, as if nothing uncommon had occurred, a slight soreness only being
experienced for the few following days.

“ We now proceed to offer one or two cases illustrative of the different symp-
toms of the disease, and may first select one which will present most of the
symptoms occurring in the course of it.

“ W., of Newton, Mass., five years of age, November, 1836. For the last two
years, this child has been troubled by an enlargement of the tonsils, first mani-
fested by a swelling which appeared on the outside of the throat, and supposed
by the parents, at the time, to be mumps. As the disease increased, the patient
gradually lost his flesh and strength, and was subject to frequent sore throat,
attended by febrile attacks, these latterly occurring as often as once in a fort-
night, and lasting two or throe days; his breathing at night was very difficult,
and accompanied with much noise. The ear of one side was inflamed, attended
wkh a purulent discharge; he was very sensitive to any loud musical sounds.
He is small of his age, thin, of an irritable disposition. The chest, on exami-
nation, is found, to be much deformed, presenting that appearance called exca-
vated sternum, it being very much depressed in its centre, and the ribs at their
union with the cartilages elevated so as to form with them an acute angle.

“ The tonsils, on examination, are so much enlarged as to touch each other, and
entirely obstruct the posterior part of the fauces; these swellings are distinctly
felt, and even visible on the outside of the throat, at the angle of the jaw; one of
the tonsils was removed, and afforded immediate relief tcr all the symptoms. In
the month of April following, some difficulty being experienced, the other was
also excised. 1 saw the patient, August 3d, 1837, nearly a year after the first
operation. From being a miserable child^and who, as his mother stated, to use
her own words, “ she had not the least idea of raising,” he has become a fine
healthy boy — has been perfectly free from difficulty of respiration, and no febrile
attack since the operation.

“ The sensitiveness of the ear had diminished, and the deformity of the chest
was much less obvious.

“The object of his calling, was from having experienced the day before some
oppression at the stomach, which induces difficulty in the respiration; and his
mother, fearing a return of his old disease, immediately brought him into town.
The symptoms were explained, by his having passed a fortnight absent from
home, where he had been allovved rather too much freedom in his diet.

“ The following is the case of a person of a more advanced age, in which deaf-
ness was produced by the disease:

“ B., aged 18 — November, 1836.

“ For two or three years has been subject to frequent attacks of sore throat; for
three months has had a purulent discharge from the right ear; is now quite deaf
in both ears, so as to require to be spoken to in a very loud voice. It is for this
deafness that he applies for advice.

“ On examination of the ears by the speculum, the tympanum on both sides
was found to be in a perfectly sound state; on the side from which the discharge
appears, the lining membrane of the ear is reddened, and covered by a purulent
deposit. The patient bears all the marks of a scrofulous constitution. The
tonsils are found to be very much enlarged, attended with considerable redness
of the back part of the fauces.

526 American Intelligence.

“Astringent remedies being tried for a fortnight without effect, both tonsils
were removed. On the following day he began to hear better; on the second
day his hearing was perfectly restored, and sounds became even so acute as to
be painful.

“ In a day or two the deafness returned, and lasted a week; he then recovered
his hearing, and has remained perfectly well since. I have seen him lately,
more than two years having elapsed since the operation; and he has experienced
no return of his difficulty.

January^ 1838. — A gentleman, twenty years of age, from the Western coun-
try, called on me with the tonsils greatly enlarged; he had been troubled with
this affection for five years, and has tried many aj^plications without effect.
For the last year he has been unable to swallow solid food without having first
snuffed a great quantity of tobacco, which apparently caused sufficient contrac-
tion or insensibility of the parts to allow of the passage of the food. If the use
of the tobacco was omitted for a single night, he found it difficult and sometimes
impossible to swallow.

“ Both tonsils were removed at the same time; very little hemorrhage
occurred, and the operation was immediately followed by great relief.

“ Miss .1., twelve years old, from Maine.

“ This child, from infancy, has been suffering from enlarged tonsils; wfithin
a few years they have become very much increased in size, so as to materially
affect her health. She is very subject to sore throat, attended with severe
febrile affections. She is of a dark complexion, black hair and eyes, quite thin,
and rather tall of her age.

“The tonsils are very large, fleshy, and vascular, and present less of that
indented appearance usually observed where there has been frequent inflamma-
tions. When the respiration is quiet, the tonsils touch each other. The chest,
on examination, is found to be very much deformed, presenting that alteration,
called excavated sternum, in its most exaggerated form; the hollow lining
almost large enough to contain a small orange: this deformity has been, for
many years, observed by her parents.

“The breathing at night is very difficult and noisy; she is subject to attacks
of deafness, and at present does not hear unless addressed in a loud voice.

“The right tonsil was removed on the 12th, and the patient at once relieved
by it; five days afterwards the other tonsil was removed, leaving the throat per-
fectly free. On the 25th I saw the patient, and the mother informed me that
all the previous bad symptoms were removed — that the child has quite recovered
her health. The difficulty of breathing is relieved, and her hearing returned; a
cutaneous eruption which had long troubled her, has disappeared.

“ To these cases might be added one or two in which these organs were
removed while the patient was labouring under an attack of severe lonsilitis.
In one case' the symptoms were immediately removed by the operation; in an-
other, inflammation had extended to the adjacent parts, and an abscess formed,
as is often seen in this disease. The affection, however, was much shortened
in duration, lasting four days, instead of fourteen, as had been usual with his
patient, who was liable to attacks every winter-. The operation was repeated,
and the other tonsil was removed on a subsequent attack, with the same result.

“ Some time since I communicated to this society the case of a young child
from Maine, who was brought to Boston suffering from a disease of the throat.
The parents seemed to be quite unconscious of the cause of its troubles. There
was great difficulty of breathing and deglutition. The child had a spoon, the
bowl of which it placed almost instinctively in its mouth when going to sleep;
its health was very miserable. The trouble was entirely explained by the
discovery of the enlarged tonsils quite obstructing the throat. The removal of
them was followed by great relief.

“ The mother informed me that another child had died with the same symp-
toms a few years previous, the cause of its illness being unknowm. They
resided in an obscure spot, distant from any competent medical advice.

“ In these cases of the disease occurring in infancy where deformity of the

American Intelligence. 527

chest exists, Dupuytren advises that this affection should be treated in the fol-
lowing- manner: — The child being placed in the lap of its nurse, the hand is
pressed on that part of the sternum or ribs which project; a strong pressure is
then made during inspiration, and removed during the movements of expiration.
This repeated for many times daily, and continued for a long period, finally
results in the disappearance of the deformity, or in a great improvement of
appearance. As has been attempted to show above, however, it will be evident
to all that the symptoms arise, certainly in the great number of cases, not from
the deformity, but from the obstruction in the throat to the free passage of air.

“The instrument* used in these operations, has usually been the guillotine
instrument, as described by Dr. Warren in his work on Tutnours, being some-
what similar to that of Dr. Physick; it is, however, without the steel moveable
needle, used to fix the tonsil and prevent it from falling into the throat, which
appears to be useless, as the blade of the instrument drives the lining mem-
brane of the tonsils into its groove, and thus secures it; and even if this were
not the case, the mucus which covers the fauces causes the excised part to
adhere to the blade, so that there is no danger of its escaping into the throat.

“In very young children, where the passage of the fauces is narrower, a more
delicate instrument, invented by Dr. Fahnestock, of Pennnsylvania, is, perhaps,
preferable.

“ From a review of the above cases, we shall find that many of the children
are of a scrofulous constitution — that the enlargement of the tonsils causes
great local trouble, attended with considerable constitutional disturbance — that
the patient is much more liable to inflammatory attacks of the throat, than in
cases where this enlargement does not exist — and that they are less liable, after
the operation^ to these attacks.

“In about half of all the cases, and in about two-thirds of the cases of chil-
dren, deformity of the chest exists. Whether this depends on the general con-
stitutional habit of the patient, or is induced by the obstruction in the throat to
the free passage of air, the accounts received from parents as to the exact time
when either affection was first observed, are not sufficiently accurate to per-
mit us to determine; it is certain, however, that this deformity does not increase,
but rather diminishes after The removal of the tonsils. The operation is a sim-
ple one, attended with no danger, and almost always affords immediate relief
to the symptoms.” — Medical Examiner, May 18, 1839.

Convention for the Revision of the Pharmacopoeia. — We are informed that
Delegates have been already appointed to the Medical Convention for the Revi-
sion of the Pharmacopoeia, which is to meet in Washing-ton in January next, by
the Medical Society of New Jersey, the University of Maryland, the College of
Physicians of Philadelphia, and Rhode Island Medical Society.

Cincinnati College. — The number of students in the Medical Department
of this College, during the session 1838-9, was 112; and at the commencement
held 3 March, 1839, the degree of M.D. was conferred upon 27 of them.

University of Virginia. — The number of medical students in this univer-
sity the past session, was fifty-seven, a larger class than had ever before assem-
bled there. The professors are, John P. Emmet, M. D. Professor of Chemistry and
Materia Medica, James L. Cabell, M. D. Professor of Anatomy and Surgery, and
R. E. Griffiths, M. D. Professor of Medicine. W ith the two first we have not the
pleasure of an acquaintance, but with the last, we have had the happiness of
many years intimacy, and from our knowledge of the extent of his acquirements,
his zeal and industry, and his high and honourable character, we feel quite sure
that he has at least contributed by his labours to the present success of the
school.

* Invented by Caleb Eddy, Esg,, of Boston.

528 American Intelligence.

Medical Department of Hampden Sidney College, i r- F i< I n >
students during the Session of 1838-9; graduated in medicine April 4, 1839, 14<.

Albany Medical College. — From the Catalogue and Circular of this Insti-
tution, which has just reached us, it appears that the number of students during
the past (first session) was sixty-eight, and that at its termination the degree of
M. D., was conferred on thirteen of them. The faculty at present consists of
Alden March, M. D., President and Professor of Surgery; Ebenezer Emmons,
M. D., Professor of Chemistry and Natural History; .lames H. Armsby, M. D.,
Professor of Anatomy; David M. M’Lachlan, M. D., Professor of Materia
Medica and Therapeutics; Gunning S. Bedford, M.D., Professor of Obstetrics;
Thomas Hun, M. D., Prefessor of Institutes of Medicine; Amos Dean, Esq.,
Professor of Medical Jurisprudence.

American Journal of Dental Science, Devoted, to Original Articles, Reviews
of Dental Publications, the Latest Improvements in Surgical and Mechanical Den-
tistry, and Biographical Sketches of Distinguished Dentists. With Plates. — The
title of this new periodical, the first number of which was published in New
York in June last, is fully expressive of its plan and object. It is edited by
Chapin A. Harris of Baltimore, and Eleazar Parmly of New York, both emi-
nent Dentists. The number before us contains several interesting original
communications and the commencement of a reprint of John Hunter’s celebrated
work on the human teeth, with notes by Mr. E. Parmly. It is the only work
of the kind in this country, and deserves, and we trust will receive, the patronage
of the cultivators of Dental Science.

The New York Journal of Medicine and Surgery. — This is the title of a new
quarterly, the first number of which was issued in New York in July last. Its
contents are creditable to the contributors; and the manner in which it is got up
equally so to its publisher, Mr. G. Adlard. We shall enrich our own pages
with notices or abstracts of its more interesting articles.

Memorial to Congress to Enact a Law for the Transmission of Vaccine Virus by
Mail free of Postage. — We have received a letter from Dr. Jas. Magoffin, Jr., of
Mercer, Mercer County Pennsylvania, in which the writer states that he has
obtained the signatures of a number of the physicians in his neighbourhood to a
memorial to congress, praying the enactment of a law for the conveyance of
vaccine matter by mail free of postage; and he urges the making of a corres-
' ponding effort by the physicians of this city, and elsewhere. The object is
certainly a useful one and deserves the active co-operation of the profession
throughout the country.

Forthcoming Work. — Dr. P. Earle, is preparing a translation of Prof. Raci-
borski’s “ Precis pratique et raisonne du Diagnostic.”

This work treats of Diagnosis under the heads of Inspection, Mensuration,
Palpation, Depression, Percussion, Auscultation, Smell, Taste, Chemical
Tests, the Interrogation of Patients, Description of the Diseases of the Skin, of
the Mouth, the Throat, and the Genital Organs ; the alterations of the Blood,
the affections of the Nervous system, and of those of the Respiratory, Circula-
tory, Digestive, and Urinary Organs, &c. &c. The Translation is from the last
French edition, which contains more than twice the quantity of matter of any
previous edition.

INDEX

Abscess, hepatic, 192, 212.

Accessory supra renal capsules, 190.

Acetabulum, fracture of, 481.

Adam on persesquinitrate of iron, 61.

Addison on disorders of the brain connected
with diseased kidney, 442,

Albany Medical College, 523, 528.

Albinos, 517.

Amputation, spontaneous, of limbs of foetus
in utero, 252.

Anchylosis of cervical vertebrse, 484.

Ansesthesia, 433.

Aneurism from anastomosis, Watson on, 24.

by anastomosis, cured by twisted

suture, 495.

■ of innominata, 225.

Angina pseudomembranacea, 73.

Annan’s report, 314.

Antonini on sulphate of quinine in the form
of ointment, for the cure of malignant in-
termittenls, 445.

Arnott’s case of disease of lining membrane
of tympanum, 491.

Arsenic, poisoning wdth, successfully treat-
ed, 243.

Artificial pupil in the sclerotica, 163.

Asthma, laryngeal, 205.

Asylum for relief of insane at Frankford,
account of, 13.

Baltimore alms house, reportof cases in, 314.

Bartlett’s case of cerebral affection, 42, 522.

Beck’s valedictory address, 431.

Belladonna [)Iaster, 450.

Bertolini and Bonacossa’s statistics of royal
insane hospital of Turin, 4l4.

Billing’s first principles of medicine, 145.

Bird on manner in which carbonic acid pro-
duces death, 505.

Births, greater number of still born in ille-
gitimate than in legitimate, 251.

Bischoff on transfusion of blood, 437.

Bladder, irritable,. 450.

— — — paralysis of, 450.

Blood, transfusion of, 437.

■ experiments on, 438.

Brain, disease of, connected with disease of
the kidneys, 442.

Bricheteau on caustic issues in phthisis pul-
monalis, 460.

No. XLVIII. August, 1839.

Bronchocele cured by croton oil, 464.

Buchanan on etiology of spontaneous ampu-
tation of limbs of foetus in utero. 522.

Burdach’s case of cartilaginous condition of
neck of uterus, 507.

Burgess on spasm of the glottis, 205.

Burne on phlegmasia dolens, 455.

Burns and scalds, 481.

Calculus, statistics of, 508.

Campbell’s case of laryngitis and broncho-
cele, cured by croton oil, 462.

Camphor, medical properties of, 198.

Carbonic acid, effects of respiring, 244.

— — gas, manner in which it causes

death, 505.

Carpenter on malignant pustule, 259.

Cai'son’s address, 431.

Carmichael on position of placenta in the
womb, 242.

Catoptric examination of eye, 255, 513.

Caustic issues in phthisis pulmonalis, 460.

Cerebral affection — double consciousness,
42, 522.

Cervical vertebrse, anchylosis and disloca-
tion of, 484.

Chapman’s introductory lecture, 184.

on diseases of the liver, 347.

Child at birth of enormous size, 504.

Cholera infantum, 301.

Chronic diseases, 422.

Churchill’s outlines of the principal diseases
of females, 394.

Cincinnati College, 527.

Club-foot, Ga.rden’s case of, 257.

, Krauss on, 491.

Coathupe on effects of respiring carbonic
acid gas, 244.

Coathupe’s experiments on products of re-
spiration at differents periods of the day,
439.

Coley’s case of luxation of ra<lius, 232.

Connecticut Medical Society; 429.

Convention for revising the Pharmacopoeia,
527

Cooper on burns and scalds, 481.

Copaiba, syrups of, 445.

Corrigan on ])aralysis of first and secotid
branches of the sensitive root of fifth pair
nerves, 451.

Coudret on medical electricity 176.

Cowan’s vital statistics of Glasgow, 246.

530

INDEX,

Crompton on injury of eye by percussion-
caps, 499.

Croton oil, remedial powers of, 445.

Cunier on hemeralopia, 242.

Darrach’s report, relative to diseases of the
eastern penitentiary, 179.

Davidson on hydrocele, 235.

■ case of malignant ulcer, 237.

— causes and treatment of erysipelas,

238.

Davy’s experiments on the blood, 438.

on fluid of vesiculae seminales, 187.

Da Luz, on kreosote, 201.

Deafness from disease of lining membrane
of tympanum, 491.

Decidua, veins of uterine, 188.

Delivery, unconscious, 243.

Dental Science, American Journal of, 528.
De lloos’s statistics of calculous diseases, 508.
Desault’s apparatus for fractures, 235.
Deslandes on onanism, 426.

Deville’s case of poisoning with arsenic, 243.
Dezeimeris on revaccination, 252.
Dieffenbaeh on cure of wry neck, 226.
Diphtheritis, 73.

Dislocation of radius, 232.

■' ■ ■ ■ ■ - of humerus, 236.

Drojisy encysted of thyroid gland, 224.
Dujat on hydrocele, 231.

Dunglison’s medical lexicon, 429.

Dunnel’s report of interments in New York,
423.

Durner on malformation of placenta, 436.

Electricity, medical, 176.

Emetics, efficacy of, in facial paralysis, 211.
Epilepsy, case of, 67.

Ergot, method of determining purity of, 196.
Erysipelas, causes and treatment of, 238.

raw cotton in, 490, 521.

Evans’s account of asylum for relief of the
insane at Frankford, 13.

Exostosis of pelvis of rapid growth, 191.

lower jaw, 516.

Eye, catoptric examination of, 255, 513.

■ ", i-ecent works on diseases of, 427.

, wound of, by percussion -cap, 281,288,

498.

Fearn’s case of aneurism of innominata, 225.
Fisher’s edition of Laennec on diseases of
the chest, 178.

Fistula, vesico-vaginal, 283.

Flint’s address, 431.

Fricke's successful employment of immove.

. able apparatus in fractures, 495.

Gallup’s instltutesof medicine reviewed, 375.
Garden’s case of club-foot, 257.

Geddings on diphtheritis, 73.

Girardin on treatment of quinsy by scarifi-
cations, 459.

Glasgow, vital statistics of, 246.

Glaucoma, Mackenzie on, 240.

Glottis, spasm of, 205.

Graves’s case of hepatic abscess, 192.

- on neuralgia of testicle, 204.

method of preparing sinapisms, 204.

treatment of hypertrophy of tonsils,

205.

Gri scorn’s case of abstraction of uterus after
delivery, 518.

Gruhn’s case of prolapsus of pregnant uterus,
307.

Guy’s experiments on the pulse, 438.

Hall’s case of unconscious delivery, 243.

Hamilton on treatment of scarlet fever, 475.

Havs on catoptric examination of eye, 255,
513.

report of cases treated in Will’s hos-
pital, 265.

- case of dislocation and absorption of
lens from wound of the eye by a grain of
wheat, 513.

extraction of foreign body from the

eye, 514.

Hayward’s case of vcsico-vaginal fistula, 283.

Heart diseases not seated in the heart, 222.

Wardrop on diseases of, 419.

Haemorrhage, Stilling’s new process for
arresting, 172.

Hemeralopia, 242.

Hepatitis, 347.

Hepaticula, 365.

Heilder on emetics in facial paralysis, 211.

Heriot’s hospital, scarlet fever in, 463.

Hilton on decussation of fibres at the junc-
tion of the medulla spinalis and m. ob-
longata, 437.

Hodgkin on mucous membranes, review of,

129.

Hulse’s case of bite of spider on glans penis,
69.

Hufeland on narcotics in form of vapour, 221.
. on heart dieases, 222.

Humerus, dislocation of, 236.

Hydrocele, 231, 235.

Ileus, gastrotomy for, 223.

Iritis, sympathetic, 500.

Iron, tritoxide of, in poisoning with arsenic,
243.

Jackson on hepatic abscess, 212.

case of twin fcetus, 256.

introductory lecture, 431.

Jorg on greater number of still-born in ille-
gitimate than in legitimate births, 251.

Journal of the medical convention of Ohio,
429.

INDEX.

531

Kermes mineral as an emetic and purgative,
195.

Knee, fungus of, 425.

Krauss on congenital club-foot, 491.
Kreosote, value of, as compared with other
remedies, 201.

Laennec on the chest, 178.

Liafargue on phrenology, 168.
l^aryngitis cured by croton oil, 462.
Lawrence’s case of exostosis of pelvis, 191.

■ ■ dislocation of humerus,

236.

Lawson’s report, 258.

Lay cock on belladonna plaster, 450.

- " ■ — - on external application of colchi-

cum in rheumatism, 450.

• on lytta in vesical paralysis, 445.

Lederle on fungus of the knee, 425.

Lee on veins of uterine decidua, 188.

- ophthalmic surgery, 427.

— — — new vaccine virus, 522.

Leg, deformity consequent on fracture, 334.
Lendrick’s case of fracture of acetabulum
481.

Lindsly on cholera infantum, 301.

Liston’s practical surgery, 179.

Liquor amnii, analysis of, 252.

Liver, abscess of, 192, 212.

diseases of, 347.

Logan on scarlatina, 71.

Loxarthrus, Mutter on, 178.

Lunatic paupers in England and Wales, 251.

Mackenzie on glaucoma, 240.

• sympathetic iritis, 500.

Maclachlan’s case of aneurism by anasto-
mosis, 495.

Magill on scarlet fever, 341,

Malcomson’s case of ranula, 493.

Malgaigne on fractures of the ribs, 485.
Malignant pustule, 259.

intermittents, ointment of sul-

])hate of quinine in, 445.

Marcy’s case of partial sweating, 66.

- — case of Albinos, 517.

Massachusetts general hospital, 262.
Medical Lexicon, 429.

Medicine, first principles of, 155.
Middlemore’s treatise on diseases of the
eye, 427.

Miner’s address, 431.

Minutes of Medical Society of Tennessee,
429.

Monod, gastrotomy for cure of ileus, 233.
Morgan’s lectures on diseases of the eye, 427.
Mortality, periodical, of human race, 250.
Mott’s gleanings, 367.

Mouchon's formulae for syrup of copaiba,
445.

Mucous membranes, Hodgkin on, 129.
Mutter on loxarthrus, 187.

Narcotics in form of vapour, 221.

Negro poisoning, 514.

Neuralgia of the testicle, 204.

New York, report of interments in, 423.

transactions of medical society

of, 429.

Journal of Medicine and Sur-
gery, 528.

Norris’s edition of Liston’s surgery, 179.

(Esophagus, cancer of, 58.

Ohio, medical convention of, 430.

Onanism, Deslandes on, 426.

Ophthalmic report, Hays’s, 265.

Osborne on irritation of the stomach, 201.
Osiander on puerperal fever, 447.

on inflammation of umbilical vein

in infarits, 461.

Osteo-sarcoma of lower jaw, 260.

Os uteri, obliteration of, 256.

Owens’s case of enormous foetus, 504.

Parker on ulceration of stomach, 214, 215.
Parry’s operation for remedying deformity
of the leg, resulting from a badly set frac-
ture, 334.

Pelvis, exostosis of, 191.

Pereira’s elements of materia medica, 413.
Persesquinitrate of iron, remedial powers
of, 61.

Phillips on division of prostrate gland in
lithotomy, 223.

Phlegmasia dolens, 455.

Phrenology, Lafargue on, 168.

Phthisis f)ulmonalis, caustic issues in, 460.
Physick, Randolph’s memoir of, 93.
Placenta, position of, in the womb, 242.

malformation of, 436.

Poisoning, Negro, 514.

Porter’s case of epilepsy, 67.

Proceedings of Connecticut Medical So-
ciety, 429.

Prostate gland, division of, in lithotomy, 224.
Prussian bills of mortality, 509.

Pueri>eral fever, 447.

Pulse, Guy’s experiments on, 438.

Quincy, treated by scarification, 459.

Rainy on urea in the blood in cholera, 251.
Randolph’s memoir of Physick, 93.

Ranula, 493.

Raw cotton in erysipelas, 490, 521.

Rees’s analysis of liquor amnii, 252.
Regnoli, extirpation of tongue, 232.
Respiration, products of, at different periods
of the day, 439.

Revaccination, 252.

632

INDEX.

Reynaud on raw cotton in erysipelas, 490.
Ribs, fractures of, 585.

Robertson on treatment of erysipelas by raw
cotton, 521.

Rodrigues’s case of exostosis of upper jaw,
516.

Roget’s outlines of physiology and phre-
nology, 432.

Rognelta’s course of ophthalmology, 427.
Romberg’s case of anaesthesia, 433.

Scarlatina as it occurred in the orphan house,
Charleston, 71.

in valley of Virginia, 341.

in Edinburgh, 463, 474, 475,478.

- ■ prevalence and mortality of, in

some public institutions in Edinburgh, 474.

— — anginosa, treatment of, 475.

Sebastian on venous circle of mammary
areola, 190.

on accessory supra renal capsules,

190.

Selwyn on dropsy of thyroid gland, 224.
Sewall’s case of wound of eye by percussion-
cap, 288.

Siehel on ophthalmia, &c., 427,

Sidey on scarlet fever, 478.

Sigmond on medical properties of zinc, 196.

camphor,

198.

— on croton oil, 445.

Silver spoon swallowed, discharged through
an abscess in epigastrium, 195.

Sinapisms, method of preparing, 204.

Solon on albuminuria, reviewed, 404..
Somervail on Negro poisoning, 514.
Somnambulism, 185.

Spider, bite of, on glans penis, 69.

Stanley’s case of dislocation and anchylosis
of cervical vertebrae, 484.

Stilling on artificial pupil, 163.

new process for arresting haemor-
rhage, 172.

Stoeber’s manual of ophthalmology, 427."
Stomach, wound of, 261.

perforation of, from morbid causes,

440.

irritation of, 201.

ulceration, 214, 215.

Sudden death, Warren on, 294.

Sulphate of quinine, ointment of, 445.
Suringar on chronic diseases, 422.

Sweating, partial, 66.

Submaxillary gland, case in which it was
extirpated, 493.

Snetin’s immoveable fracture apparatus, 495.
Spontaneous amputation of limbs of foetus
in utero, 522.

Tavlor on perforation of the stomach, 440.
Telangiectasis, Watson on, 24.

Tennessee, medical society of, 429.
Testicle, neuralgia of, 204.

Thyroid gland, 224.

Tongue, extirpation of, 232.

Tonsils, hypertrophy of, 205, 523.
Toulmouche on kermes mineral, 195.
I'ransactions of the Medical Society of New
York, 429.

Trinchinetti on turpentine in diseases of the
eye, 242.

Turpentine in diseases of the eye, 242.
Twin foetus, one expelled prematurely, the
other retained to full term, 256.
Tympanum, diseases of lining membrane of,
491.

Ulcer, malignant, 237.

Umbilical vein, inflammation of, 461.

Urea in the blood in cholera, 251.

Uterine decidua, veins of, 188.

Uterus, manner in which it expands, 242.

, cartilaginous condition of neck of,

507.

, prolapsus of, 507.

, abstraction of, after delivery, 518,

520.

V -

Vaccine virus, new, 258, 522.

, memorial to congress to al-
low it to be conveyed by mail free, 528.
Veins of uterine decidua, 188.

Venous circle of the mammary areola, 190.
Verdet’s case of natural somnambulism,
185.

Vesico-vagiual fistula, case of, 283.

Vesiculse semiuales, fluid of, 187.

Virginia, University of, 527.

Wardrop on diseases of the heart, 419.
Wardleworlh’s method of determining pur-
ity of ergot, 196-

Warren’s case of sudden death, 294.

on enlargement of tonsils, 523.

Watso)i on telangiectasis, 24.

AVeber’s case of closure of os uteri, 256.
White’s lunatic asylum, 262,

Wills’s hospital, report of cases treated in,
265.

Wood on scarlet fever of Edinburgh, 463.
Wort’s case of osteo-sarcoma of lower jaw,
260.

Wound of stomach, 261.

Wry neck, cured by dividing sterno-cleido-
mastoid muscle, 226.

Wyman’s case of cancer of oesophagus, 58.

Zinc, medical properties of, 196.

529

QUARTERLY MEDICAL ADVERTISER.

In consequence of the extended circulation of the American Journal of the
Medical Sciences, the Proprietors intend, in compliance with the wishes of
many of their friends, to prefix to each No. a Sheet of Advertisements. All
Booksellers, Medical Gentlemen, and others desirous of taking- advantage of this
mode of announcement, will please address their Advertisements to Lea &
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MEDICAL CONVENTION.

In obedience to a resolution of the Medical Convention of the United States, assem-
bled in Washington City in January, 1830, public notice is hereby given, that a similar
Convention vmII meet at the National Motel, in the said city, on the first Wednesday of
January, 1840, for the purpose of revising the Pharmacopceia of the United States.

By order of the Medical Convention, assembled at Wasliington, in .T inuary, 1830.

LEWIS CONDICT, M.D., President.

Morristown, New Jersey, April 6, 1839.

UNIVERSITY OF PENNSYLVANIA.

MEDICAL DEPARTMENT.

The Lectures commence annually on the first Monday of November, and con-
tinue until the ensuing March.

Theory and Practice of Medicine,
Institutes of Medicine,

Special and General Anatomy,
Materia Medica and Pharmacy,
Chemistry,

Surgery,

Obstetrics and Diseases of Women and
Children,

By Nathaniel Chapman, M. D.
By Samuel Jackson, M. D.

By William E. Horner, M. D.
By George B. Wood, M.D.

By Robert Hare, M. D.

By William Gibson, M. D.

By Hugh L. Hodge, M. D.

Clinical Medicine and Surgery taught by the prescribing Medical Officers at
the Blockley Hospital, under the Guardians of the poor, and at the Pennsyl-
vania Hospital.

W. E. HORNER, M.D.

Dean of the Medical Faculty*

5‘JO

Quarterly Medical Advertiser,

JEFFERSON MEDICAL COLLEGE PHILADELPHIA.

SESSION OF 1839-40.

The regular Lectures will commence on the first Monday ofNovember. The following
are the Professors in the order of their appointment.

Jacob Green, M. D.,

Samuel M’Clellan, M. D.,

Granville S. Pattison, M. D.,

John Revere, M. D.,

Robley Dunglison, M. D.,

Robert M. Huston, M. D.,

Joseph Pancoast, M. D.,

Professor of Chemistry,

^ Professor of Midwifery and Diseases of Women and
f Children. „

Professor of Anatomy.

Professor of the Principles and Practice of Physic.
5 Professor of Institutes of Medicine and Medical
f jurisprudence.

Professor of Materia Medica and Pharmacy.
Professor of Principles and Practice of Surgery.

On and after the first of October, the Dissecting rooms will be kept open, and the
Professor of Anatomy will give his personal attendance thereto. Lectures will likewise
be delivered regularly during the month on the various branches, and opportunities
for Clinical Instruction will be afforded at the Philadelphia Hospital under the Professor
of Institutes of Medicine and at the Dispensary of the College under the Professors of
Pl)ysic and of Surgery.

Fee for each Professor for the whole course, 9^15.

Graduation Fee, $30.

JOHN REVERE, M. D.

Dean of the Faculty.

MEDICAL COLLEGE OF THE STATE OF S. CAROLINA.

The annual course of Lectures of the Medical College of the State of South
Carolina, will commence on the second Monday of November.

J. Edwards Holbrook, M. D.,
John W^agner, M. D.,

S. Henry Dickson, M. D.,
James Moultrie M. D.,
Thomas G. Prioleau, M. D.,
C. M. Shepard, M. D.,

Henry R. Frost, M. D.,

E. Geddings, M. D.,

F, Wurdemann, M. D.,

Professor of Anatomy.

Professor of Surgery.

Professor of Institutes and Practice of Medicine,
Professor of Physiology.

Professor (f Obstetrics.

Prtfessor of Chemistry.

Professor of Materia Medica.

Professor of Pathological Anatomy and Medical
Jurisprudence.

Demonstrator of Anatomy.

JAMES MOULTRIE, M. D.,

Dean of the Faculty.

university of the state of new YORK.

COLLEGE OF PHYSICIANS AND SURGEONS OF NEW YORK.

The Lectures in this Institution will commence on the first Monday of November,
and continue for four months.

Professor of Physiology.

\ Professor of the Theory and Practice of Physic and
( Clinical Medicine.

\ Professor of Materia Medica and Medical Juris-
L prudence.

Professor of Chemistry and. Botany.

Professor of Special and General Anatomy.

S Lecturer on Surgery and Surgical and Pathological
) Anatomy.

\ Lecturer on Obstetrics and the Diseases of Women
f and, Children.

The cxpence of attending a course of Lectures by all the Professors is $108.

J. AUGUSTINE SMITH, M. D.. President.
NICOLL H. DERING, M. D., Registrar.

New York, July 1, 1839.

J. Augustine Smith, M. D.,
Joseph M. Smith, M. D,

John B. Beck, M. D.,

John Torrey, M. D.,
Robert Watts, Jr. M. D.

Willard Parker, M. D.,
James R. Manley, M. D.,

Quarterly Medical Advertiser. 531

COLLEGE OF PHYSICIANS AND SURGEONS

OF THE

WESTERN DISTRICT OF THE STATE OF NEW YORK,

(Fairfield Herkimer County.)

The Lectures commence on the 1st Monday of October, and continue sixteen weeks^
Anatomy and Physiology^ By James McNaughton, M. D.

Chemistry and, Pharmacy,, By James Hadley, M, D.

Materia Medica and Medical Jurisprudence,, By T. Romevn Beck, M. D.

Practice of Physic and, Obstetrics^ By John Delamater, M. D.

Surgery, By Frank H. Hamilton, M. D.

Fees for the whole course, $56.

JAMES HADLEY, M. D.

Registrar.

MEDICAL INSTITUTION OF YALE COLLEGE.

The Lectures in this Institution will commence on Thursday, October 3, 1839, and
continue sixteen weeks.

Professor of Chemistry, Pharmacy, Mine-
ralogy and Geology.

Professor of the Theory and Practice of
Physic.

Professor of Materia Medica and Thera-
peutics.

Professor of the Principles and Practice
of Surgery.

Professor of Obstetrics.

Professor of Anatomy and Physiology.

The Fees, which are required in advance, are ^12,50, for each co.ursc, except that
on Obstetrics, wliicfi is $6. The Matriculation fee is ^5, and the contingent bill for
the course on Cliem’stry $2,50. The expense of a full course therefore is $76. The
graduation fee is $15.

CHARLES HOOKER, M. D.

Secretary.

Benjamin Silliman, M. D., L. L. D ,
Eli Ives, M. D.,

William Tully, M. D,

Jonathan Knight, M. D.,

Timothy P. Beers, M. D.,

Charles Hooker, M. D.,

CINCINNATI COLLEGE.

MEDICAL DEPARTMENT.

The Lectures commence annuallv on the last Monday of October, and continue
until the commencement, or time of conferring the degrees.

Anatomy Special and Surgical,

General and Pathological Anatomy, and Physiology,

Surgery,

Obstetrics and Diseases of Women and Children,

Chemistry and Medical Jurisprudence,

Materia Medica and Pharmacy,

Theory and Practice of Medicine,

Demonstrator of Anatomy,

By a Recent law of the Ohio Legislature Students of Medicine of this School are
admitted to attend the wards of the Commercial Hospital and Lunatic Asylum in this
city upon the same terms as those of the Ohio Medical College.

JOHN P. HARRISON, M. D.

Dean of Medical Faculty.

By J. N. M’Dowell, M. D.
By S. D. Gross, M. D.

By Willard Parker, M. D.
By L. C. Rives, M. D.

By James B Rogers, M. D.
By John P. Harrison, M, D.
By Daniel Drake, M. D.

By Carey A. Trimble, M. D.

533

Quarterly Medical Advertiser,

ANNUAL CIRCULAR

OF THE

MEDICAL COLLEGE OF LOUISIANA,

FOR 1839-40.

F A C U L Y .

John Harrison, M. D , Professor of Physiology and Pathology.

Edward H. Barton, M. D., Professor of Materia Medico, Therapeutics and Hygeine.
James Jones, M. D., Professor of the Theory and Practice of Medicine.

J. \j. Riddei.l, M. D., Professor of Chemistry and Pharmacy.

Warren Stone, M. D., Professor of Surgery.

G. A. Nott, M. D., Professor of Anatomy.

A. H, Cenas, M. D., Professor of Obstetrics and the Diseases of Women and Children,
G. W. Morgan, M. D., Demonstrator of Anatomy.

The Session will open at the Charity Hospital, on Common Street, on the first Monday
in December, and close on the fourth Saturday in March. The commencement for
conferring Degrees will be held on the Wednesday following the close of the Lectures.

E. H. BARI ON, M. D., Dean.

New Orleans, May, 1839.

At the Annual meeting of the Physico-Medical Society of New Orleans, the following
Members were duly elected officers for the year, viz:

G. H. Barton, M. D., Presiderd.

G. W. Campbell, M. D.,

J. M. W. PicTON, M. D.,

J. S. Snowden, M. D.,

.Presidents.

G. Betteur, M. D.,
T. O. Menx, M. D.,
T. Hunt, M. D.,

^ Vice-i

Corresponding Secretary.

Recording Secretary.
Treasurer.

Curator.

ALBANY MEDICAL COLLEGE.

This institution received its charter from the legislature of the state during the past
winter, and commenced operations with a class of sixty five students; thirteen of whom
received the degree of Doctor in Medicine at the close of the session.

The College Edifice and its accommodations: the Museum, 'Pheatre, Dissecting
Rooms, and Laboratory, are all on a scale of magnitude and excellence, equal it is
believed, to any similar institution in the country.

Choice and extensive collections of Anatomical Specimens and morbid preparations;
with cabinets of Materia Medica, Botany, Minerah)gy, Geology and Zoology, together
with Casts, Plates, Drawings, Models, Instruments and apparatus for illustrating the
different departments of study, have all been provided and arranged in the Museum
of the College, which will be open for the inspection of students during the lecture
term.

The ensuing Session will commence on Tuesday, October 1st. 1839, and continue
sixteen weeks.

The faculty consists of the following gentlemen.

Alden March, M. D, President, and Professor of Surgery.

Ebenezer Emmons, M. D., Professor of Chemistry.

David M. Reese, M. D., Professor of the Theory and Practice of Medicine.

James H. Armsbv, M. D., Professor of Anatomy.

David M. M’ Lachlan, M. D^ Professor of Materia Medica and Iherapeutics.
Gunning S. Bedford, M. D , Professor of Obstetrics.

3’homas Hun, M. D., Professor of the Institutes of Medicine.

Amos Dean Esq., Professor of Medical Jurisprudence.

The fee for all the courses is $70. Matriculation fee $5. Graduation fee $20.
Price of boarding from $2,50 to $3,50 per week.

For further particulars inquire of either of the Faculty, or of

JAMES H. ARMSBY, M. D,

Registrar.

Albany, July, 1839.

Quarterly Medical Advertiser,

533

nrMUNN’S ELIXIR OF OFIUM.

CIRCULAR TO PHYSICIANS.

~Nevo Yorky March 1, 1839.

Dear Sir: — I beg leave to solicit your favour and patronage to iny ELIXIR OF
OPIUM, a new chemical preparation, which I have invented, containing all the valu-
able medicinal princi|»lcs of Opium, to the exclusion of those which are deleterious and
useless, and which, I feel assured, will be found worthy of your kind attention.

It is a well ascertained fact, that Opium, in its natural state, is not a simple sub-
stance, but is found, by chemical analysis, to contain the Meconate of Morphia, Codein,
and Narcein, which are valuable elements; and Narcotine, Gum, Resin, Feculent Mat-
ter, &c., wliich are noxious principle.-; and lull proportions of the greatest number of
which are contained in Laudanum, Paregoric, Black Drop, Denarcotized Laudanum,
and such other opiate preparations of this class hitherto made, and to which are justly
attributed those disagreeable effects upon the stomach and nervous system, which so
frequently follow their operation and limit their usefulness.

This .ELIXIR OF OPIUM retains only the Morphia, Codein, and Narcein, and
these in combination with its native Meeonic Acid; in consequence of this, and the
undecomposed combination of all these, its remaining principles, it produces the cha-
racteristic effects of the Opium more distinctly than any of the artificial compounds of
Morphia; fully confirming the fact, that the more undecomposed and unchanged we
keep the native elements of substances in pharmaceutic preparations, the more charac-
teristic will be their therapeutic effects upon the animal system; — and intimately con-
nected with this fact, is the circumstance of the absolute impossibility of restoring the
original valuable qualities of vegetable substances, to the result of the artificial combi-
nation of their decomposed proximate principles.

And thus it is, after the native Me'onate of Morphine has been decomposed by che-
mical process, that its natural proportions, so necessary and essential to the preserva-
tion of the identity and characteristic virtues of the native drug, are never maintained
in an artificial combination. Its organic nature is so destroyed, and its strength so
materially impaired by insolubility, that it is comparatively inert and useless.

It also demonstrates another fact, the importance of which will be obvious to all medi-
cal chemists, namely, the high superiority of the native acid of this preparation, to the
artificial ones of those forms of Morjihia hitherto used; for it is will known that the
nature and power of Saline compounds materially depend upon tlicir acidilying prin-
ciple; as the difference between the Arseniates of Potass and Soda, and the Sulphates,
Nitrates and Muriates, of the same alkalies will exemplify.

Although the native Meconic Acid in an isolated state, may not appear to possess
any medicinal activity or to exert any action upon the animal system, yet when com-
bined, in a natural state, with Morphine, Codem, and Narcein, as in the Elixir of
Opium, it acquires activity from them, and imparts virtue and power to them, of
which neither the Acetic, Sulphuric, Muriatic or any other Artificial Acid is capable,
and their native combination and compound effects possess more proportionate energy,
than either can individually, or with any artificial principle substituted for them; the
difference in the nature and power of the artificial Salts of Morphine, shows a decided
superiority of some of their Acid.s to others, namely, of the Acetic and Sulphuric to the
Muriatic, Nitric, Tartaric and Carbonic, and of the greater solubility of their Salts,
and consequently superior power and preference; and those of the others being less
soluble, are proportionably less active. It is impossible for the Morphine alone, and
that in artificial combination, to fully represent and maintain in medical treatment all
the physiological influence.s and medicinal virtues of so triumphant a remedy as Opium
is, when so many of its other valuable properties are excluded.

That Codein and Narcein possess the characteristic and many of the essential virtues
of the Opium, and that when associated in native combination with the Meconic Acid
and Morphine, they confer much additional strength and impulse to a preparation, as
they do in the Elixir of Opium, is undeniable.

The great discrepancy in the comparative strength between Morphine and the native
drug, independent of insolubility, principally depends upon the exclusion of those prin-
ciples, and accounts for the circumstance, why “one grain of Morphine produces no
more effect than two grains of Turkey Opium, w'hich do not contain more than a six-
teenth part of the Alkali.”

534 Quarterly Medical Advertiser,

It possesses, also, a superior advantage to the Solutions of Morphia, (in addition to
that of containing tlie Codein, Narcein and Meconic Acid, in a natural state of combi-
nation,) in its being of uniform strengtii, and not liable to decomposition and deterio-
ration from those constant changes which the variable temperature, to which they are
exposed, occasions; and thus is obviated a serious objeetion, whieh has prevented their
being used with preeision and safety.

The applicability of so highly improved a preparation as this Elixir of Opium, to a
wide range of human diseases, scarcely needs an illustration, since Opium itself, in
some form or other, with all its objectionable elements, is considered almost indispen-
sable in cases of constant occurrence.

To speak summarily, the Elixir of Opium may be adopted in all cases in which
either Opium or its preparations are administered, with the certainty of obtaining all
their sedative, anodyne, and antispasmodic effects, without being followed by the disa-
greeable consequences of hea'laclie, nausea, vomiting, constipation, tremors, and a train
of other unhappy symptoms, which are often as distressing as those wliich it was
applied to remove.

N<jr is the prevention of these consecutive ill effects, the only important desideratum
which recommends this valuable discovery to favourable notice. Its almost universal
applicability in the treatment of the great number of diseases, in which other opiates
are contra-indicated and inadmissible, in consequence of their stimulating and consti-
pating effects, at once entitles it to universal adoption.

It possesses yet another important advantage, which is of paramount consideration
in the treatment of some of the most violent and dangerous spasmodic diseases, such as
Tetanus, Epilepsy, Hysteria, Tic douloureux, Convulsions in Hydrophobia, &c. &c.,
whieh is that the quantity necessary to overcome and control diseased action in those
dreadful rnaladies, is not limited by the deleterious influence of those objectionable
principles, but can be given in large quantities wuth safety, inasmuch as their propor-
tions in Opium and its several preparations containing them, are so great, that by the
time a sufficient quantity is taken, for the anodyne and antispasmodic properties to
allay and overpower the pain and spasmodic action in some of their most violent
attacks, the poisonous influence of the objectionable elements, will preponderate and
produce narcotism, stupor, and apoplectic death; and the patient dies the victim of the
poisonous effects of the intended remedy, before the valuable properties can give the
desired relief

Having used this preparation for some time in an extensive medical practice, and
being fully satisfied of its value, I therefore take the liberty to submit it to the mem-
bers of the Medical Profession, with full confidence that it will obtain the approbation
of their judgment, and be eminently successful in their enlightened practice.

Your most obedient servant,

JOHN B. M’MUNN.

N. B. Full directions accompany each vial, and the signature of my name, in full,
on the outside label.

TESTIMONIALS.

Dr. John B. M’Munn having made known to me the process by which he prepares
his “ ELIXIR OF OPIUM,” and wishing me to state my opinion concerning it, I
therefore say, that the process is in accordance with well known chemical laws, and that
the prepiration must contain all the valuable principles of Opium, without those which
are considered as deleterious and useless.

New York, December 29, 1836. J. R. CHILTON, M. D.

Operative Chemist, &c.

Dr. J. B. M’Munn.

Dear Sir; — I have mirde repeated trials of your “ Elixir of Opium” in the City and
Marine Hospitals, and find it to possess the anodyne and sedative powers of the ordi-
nary preparations of Opium, without producing the excitement, headache, nausea, and
constipation, which in many cases render those preparations objectionable.

Its effects are move permanent and uniform than those of Morphia.

Yours, »&c.

C. L. MITCHELL, M. D.

Resident Physician, New York Hospital.

New York, February 8tk, 1837.

535

Medical Quarterly Advertiser.

Bellevue, New York, February 19, 1839.

This is to certifyy, that Dr. J. B. M’Munn’s Elixir of Opium has been used in
sever .1 cases, at tiie Bellevue Hospital, with the most satisfactory effects, when the
usual preparations of Opium would have proved injurious.

The undersigned are fully convinced, that it possesses the sedative properties of the
latter, without producing constipation of the bowels, or any unpleasant symptoms.

HENRY VAN HOEVENBERGH,

Resident Physician.

GEORGE F. ALLEN, ,

Assistant Physician, J

From Dr. James Heron, President of the Medical Society of Orange County, New
York.

This Certifies, that I have used of Dr. M’Munn’s Elixir of Opium, and do find it
to be preferable to Opium and its tinctures, in that it is not followed by the pain in the
head, nausea, dry and bitter mouth, and constipation, so generally consequent upon
the use of that drug. And I do !elieve his preparation, at least, equally beneficial with
the other combinations of Morphia.

JAMES HERON, Physician and Surgeon.

Warwick, October llth, 1836.

The following from Ansel W. Ives, A. M.* speaks volumes.

IMPORTANT COMMUNICATION. — About ten months ago I was attacked with
a very painful species of Neuralgia, [Tic douloureux,] affecting all the nerves of one of
my hips and legs, which excepting occasional short intervals, has continued with una-
bated severity to the present time. As no remedy has ever seemed to produce the
least permanent effect in the progress of the disease, I have been obliged to rely entirely
on Opium to mitigate intolerable pain. I began by using the Black Drop, and after-
wards the different preparations of Mor[)hine, both by taking them into the stomach
and by applying them to a blistered surface externally. By these preparations my
digestive functions were almost entirely suspended, and my whole nervous system so
disturbed, that my general health was suffering severely from the use of them. It was
but a short time before I was taken ill, that Dr. M’Munn had left with me a specimen
of his Elixir of Opium, witli the request that I would make a trial of it in my prac-
tice. I had not used it enough, however, before my sickness, to form any opinion of
its peculiar virtues, and I confess I was not predisposed to believe that it possessed
any; but one of my medical attendants suggested the propriety of my using it, as all
other preparations of Opium affected me so unfavorably. From that lime to the present,
a period of about eight months, I have taken but little less than 100 ounces of this medi-
cine. As I can therefore speak with great confidence as to the effect of Dr. M’Munn’s
Elixir in my own case, it is not less an act of justice to him, than a duty to the profes-
sion, and to the cause of humanity, that 1 give a brief statement of its peculiar effects,
and of its superiority in my own case over every other preparation of Opium.

In the first place, it has never impaired my appetite, nor weakened the powers of
digestion, on the contrary, when taken in moderate quantities, that is, in doses from
half a drachm to a drachm three or four times in twenty-four hours, it has seemed to

* Of Dr. Ives, it is sufficient to say, that he was an eminent physician in the city of
New York, and is well known to the medical profession generally as a scientific medi-
cal chemist, wliose name stands recorded in connection with Lupuline (the active prin-
ciple of the Hop,) of wdiich he was the discoverer. Medical science is also indebted to
him for testing the qualities of other valuable medicines, and for their more general
introduction into practice. And it may in fact, be said, that a more capable person
could not have been selected to test the qualities of the Elixir of Opium than him, nor
a more befitting disease for that purpose, than the one with which he was so sorely
afflicted.

1-BeZ/euMe Hospital.

436

Medical Quarterly Advertiser.

increase the digestive functions; and even though I have taken during the last fifteen
days as many ounces of the Elixir, my appetite is still good. Secondly, it does not pro-
duce relaxation of the skin, and consequent perspiration as other preparations of Opium
do. Tliirdly, it uniformly increases the secretion of urine. Fourthly, unless taken in
uncommonly large doses, it does not produce constipation of the bowels. Fifthly,
although it has been equally efficient in relieving pain, it has in no instance caused head-
ache^ or sicknesss of stomach, or any of those symptoms of nervous irritability of the
system which usually ensue from other preparations of Opium, after their primary
influence has subsided. Without going into detail, such are the peculiarities of the
“Modus Operand!” of Dr. M’Munn’s Elixir in my own case. How far its action by
future experience may be found to correspond with this on other constitutions I pre-
pretend not to say; but I think I shall be sanctioned by my medical attendants in
adding, that my life has already been prolonged by the peculiar benefits derived from
this medicine.

A. W. IVES, M. D.

New York, Dec. 14, 1837.

Having witnessed the effects of Dr. J. B. M’Munn’s Elixir of Opium, we are of
opinion that it is a valuable preparation, and recommend it to the patronage of the
profession.

F. U. JOHNSTON, M. D.

President of the Medical Society of New York, and Physician to the City

and Marine Hospital.

JOHN W. FRANCIS, M. D.

Late Prof, of Midwifery in the College of Phys. and Surgeons, N Y.

JOHN C. CHEESEMAN, M. D.

Surgeon to the New York City Hospital.

RICHARD K. HOFFMAN, M. D.

Surgeon to the City Hospital, N. Y. and late Surgeon in the U. S. N.
JAMES WEBSTER, M. D.

Prof, of Anat. and Physiology in the Geneva Medical College, N. Y.

New York, Feb. 18, 1837.

Messrs. A. B. and D. Sands, No. 79 Fulton St., North East corner of Gold St., and
No. 100 Fulton, corner of William St. New York, are the general wholesale agents,
and will supply all orders on the most favourable terms. Also for sale by C. Ellis &
Co., 56 Chesnut St. and C. M. Wilstach, 270 Arch St. Philadelphia; by G. K. I'yler,
corner of East Baltimore and Hitrh St., and R. H. Coleman & Co., Baltimore; by Havi-
land, Harrall, Allen, and P. M. Cohen & Co., Charleston, S. C.; by Haviland, Risley &
Co, Augusta, Ga.; by Wm. Brown, 481 Washington St. Boston; by Andrew Oliver,
New Orleans, and Du Bose & Roff, Mobile, and by druggists generally in almost all
of the principal cit»es and chief towns in the United States.

O’ Physicians and druggists can supply themselves with this valuable preparation,
by addressing their orders to almost any of the principal druggists in New York,
Philadelphia, Baltimore, or Boston. Price 37^ cents.

Caution. — -Purchasers are particularly desired to ask for M’Munn’s Elixir of Opium,
as there are spurious imitations, which bear no resemblance, except in name, and ob-
serve the written signature of “John B. M’Munn” on each bottle.

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